Travail du sexe, prostitution, état de santé et accès aux soins

Bibliographie thématique

Février 2026

Centre de documentation de l’Irdes

Véronique Suhard

Synthèses & Bibliographies

Reproduction sur d’autres sites interdite mais lien vers le document accepté www.irdes.fr/documentation/syntheses-et-dossiers-bibliographiques.html

Sommaire

Problématique : Des enquêtes peu nombreuses et parcellaires. 3

La situation des travailleurs et travailleuses du sexe : généralités. 3

En France. 3

a l’etranger. 7

Etat de santé physique et mentale des travailleurs du sexe. 12

Quelques Revues de littérature. 12

EN France. 20

A l’étranger. 25

Obstacles et interventions facilitant l'accès aux services de santé. 43

Revues de littérature. 43

En France. 49

A l’étranger. 60

Problématique : Des enquêtes peu nombreuses et parcellaires

Les connaissances sur les travailleuses et travailleurs du sexe et les personnes en situation de prostitution en France restent très incomplètes. Aujourd'hui, on ne connaît ni leur nombre, ni leurs conditions de vie, ni leur état de santé, leur accès aux droits et aux soins.

En 2016, la Haute Autorité de Santé avait réalisé un état des lieux des connaissances sur la situation sanitaire des personnes en situation de prostitution et sur les facteurs de vulnérabilité sanitaire de ces personnes, afin d’établir des recommandations de bonnes pratiques validées sur les problématiques sanitaires vis-à-vis desquelles les personnes en situation de prostitution/tds sont particulièrement exposées [1]. Ses conclusions faisaient apparaître les nombreuses zones d’ombre dans la connaissance de ces problématiques.

L’enquête Tessa (Travail du sexe, prostitution, santé, soins et assurance) de l’Irdes tente de combler les manques. C’est une enquête statistique, à visée représentative [2]. Cette bibliographie a été réalisée dans le cadre de cette enquête.

Les recherches bibliographiques ont été réalisées sur les bases suivantes : base bibliographique de l’Irdes, de Cairn, Medline et Google scholar, sur une période allant de 2010 à 2025 (sauf exceptions). Cette bibliographie concerne principalement la France et d’autres pays de l’OCDE et ne prétend pas à l’exhaustivité.

Elle est structurée en trois axes principaux : état des connaissances sur la prostitution et les travailleurs du sexe (législation, problématiques sociétales, données statistiques, méthodologies d’enquête). Elle s’attache ensuite à décrire l’état de santé physique et mental de cette population avant d’examiner les difficultés d’accès aux soins et des exemples d’interventions pour tenter d’y faire face.

La situation des travailleurs et travailleuses du sexe : généralités

En France

Bergheul, S., et al. (2020). "La prostitution: facteurs d’entrée, de sortie et interventions." Sexologies 6(2): 82-91.

https://stm.cairn.info/revue-sexologies-2020-2-page-82

Cet article examine les facteurs d’entrée et de sortie de la prostitution, ainsi que les interventions visant le soutien des femmes désirant quitter le monde prostitutionnel. Malgré la diversité des trajectoires menant à l’industrie du sexe, la prostitution est fortement liée à des problèmes psychologiques, familiaux, sociaux et/ou économiques. Ces facteurs maintiennent les femmes dans la prostitution et complexifient le processus de sortie. Il est impératif, en ce sens, d’établir une compréhension permettant de saisir les mécanismes d’entrée et de sortie de la prostitution afin de mieux cibler les interventions en matière de prévention et mieux soutenir les femmes désirant quitter la prostitution. Une recherche, à partir de plusieurs bases de données, a permis de sélectionner 21 études portants sur les mécanismes d’entrées, de sortie et sur les interventions. Les étapes de la démarche de recension des écrits sont inspirées de la démarche du Centre for Reviews and Dissemination de l’université de York (2008). Les résultats montrent que l’entrée dans la prostitution est la conséquence de facteurs multiples et la sortie nécessite un processus complexe qui exige plusieurs tentatives. Certains programmes d’interventions ne répondent pas à des besoins spécifiques aux femmes prostituées.

Coppel, A. (2020). "Le Bus des femmes. Prostituées, histoire d’une mobilisation". Paris : Anamosa.

En 1990, une prostituée de la rue Saint-Denis sollicite une sociologue spécialisée dans la lutte contre les toxicomanies afin qu'elle l'aide à mobiliser les pouvoirs publics sur la santé et les conditions d'exercice des prostituées, en plein épidémie de sida. Leur action aboutit à la création du Bus des femmes en 1991. Ce document témoigne de leur mobilisation.

Duché, G., et al. (2018). "La lutte contre le système prostitutionnel, une politique publique française. Forum n° 155(3): 43-54.

https://shs.cairn.info/revue-forum-2018-3-page-43

La prostitution et la traite des êtres humains à des fins d’exploitation sexuelle, son corollaire, sont incluses dans les violences à l’encontre des femmes depuis 2011. En 2016, après de nombreux débats, l’abolitionnisme français a été complété par une loi de « renforcement de la lutte contre le système prostitutionnel et de l’accompagnement des personnes prostituées ». Celle-ci met en place une politique publique globale qui s’appuie sur plusieurs types d’actions. La loi dépénalise les victimes et responsabilise les auteurs de violence, les clients de la prostitution ; elle prévoit aussi d’accroître les moyens d’accompagnement vers la sortie de la prostitution notamment celle des personnes étrangères soumises à la traite. Cet article propose une analyse des fondements et du contenu de la loi ainsi qu’une première évaluation de son application.

Fosu Twum, B. (2017). "Prostitution et travail social." Le Sociographe  59(3): 59-65.

https://shs.cairn.info/revue-le-sociographe-2017-3-page-59

Souvent considérée comme étant le plus vieux métier du monde, la prostitution fait l’objet de nombreux débats passionnés. Marqué par de fortes représentations dans la société, ce sujet controversé dérange, choque ou fascine. Deux camps s’opposent autour de la prostitution : les réglementaristes et les abolitionnistes. La loi du 13 avril 2016 a marqué le point d’ancrage de nouveaux débats entre eux. Elle pose ainsi la question du bien-fondé de la prostitution. Quelles peuvent être les conséquences de cette loi sur les pratiques des prostituées et de leurs clients ?

Gaudillat, S. (2022). "La prostitution des mineures, une problématique nouvelle de la politique de la ville ?" Les Cahiers du Développement Social Urbain N° 76(2): 22-23.

https://shs.cairn.info/revue-cahiers-du-developpement-social-urbain-2022-2-page-22

L’annonce, en novembre 2021, du premier plan national de lutte contre la prostitution des mineur·e·s manifeste la volonté de l’État de se saisir enfin d’une problématique qui, si elle n’est pas nouvelle, prend aujourd’hui une ampleur sans précédent. Les territoires de la politique de la ville n’y font pas exception, aux dires des professionnel·le·s. Stéphanie Gaudillat, ancienne directrice d’une structure d’accompagnement des personnes en prostitution, aujourd’hui consultante et formatrice, s’intéresse plus particulièrement aux conséquences de la prostitution des mineur·e·s en matière de santé.

David, M. (2014). "Penser le fait prostitutionnel : Enjeux moraux et politiques de la question sanitaire dans le traitement sociétal d'une activité stigmatisée". Nantes : Université de Nantes. Thèse de doctorat en sociologie

https://theses.fr/2014NANT3005

Cette recherche s'efforce d'articuler le niveau macrosocial des fondements normatifs, historiquement situés, sous-tendant le fait prostitutionnel et l'échelle plus microsociale des actions de santé conduites auprès des personnes se prostituant. La première partie de la thèse interroge la nature problématique de la prostitution pour la démarche sociologique, du fait des antagonismes qu'elle suscite, et met en exergue la nécessité d'affronter cette particularité en expliquant les idéaux engagés dans la controverse. Outre cette clarification permettant de rapporter de telles dissensions à la question de la libre disposition de soi face à l'érosion des modes de régulation traditionnels, le fait d' « historiciser » le phénomène concerné amène à constater que celui-ci a perdu tout caractère d'évidence dans nos sociétés occidentales contemporaines, contrevenant désormais aux schèmes de pensée qui gouvernent notre sexualité. La seconde partie de l'analyse présente les résultats d'une enquête ethnographique effectuée en Belgique et en France au sein d'associations réalisant des actions de prévention des infections sexuellement transmissibles ou proposant des consultations médicales dédiées aux prostituées. Complétée par un examen de l'utilisation du registre sanitaire dans la littérature militante, cette étude comparative a permis de faire ressortir les enjeux moraux et politiques impliqués dans la définition des risques menaçant les intéressées mais aussi la participation de ces interventions à la mise en forme collective de l'expérience prostitutionnelle.

Mathieu, L. (2007). "La condition prostituée". s.l. Textuel

Lilian Mathieu rend compte ici de plus de dix ans d'étude attentive de cet univers particulier qu'est la prostitution. Les logiques d'entrée dans le monde du trottoir, les modes d'exercice de la sexualité vénale, les conditions de vie - ou, le plus souvent, de survie - des femmes et hommes prostitués, les raisons pour lesquelles elles et ils se maintiennent sur le trottoir, leur rapport au monde du travail "normal" sont ici analysés dans toute leur complexité. C'est parce qu'elles ignorent cette complexité que les positions qui monopolisent le débat public sur la prostitution sont insatisfaisantes. L'auteur montre que la polémique entre reconnaissance ou abolition de la prostitution est stérile. C'est en plaçant cette activité marginale au cœur de la question sociale que la condition prostituée pourra espérer trouver une forme d'émancipation.

Mission interministérielle pour la protection des femmes contre les violences et la lutte contre la traite des êtres humains (2025). "Le système prostitutionnel", Paris (Miprof).

https://arretonslesviolences.gouv.fr/sites/default/files/2025-04/Lettre%2024%20de%20l%27Observatoire%20national%20des%20violences%20faites%20aux%20femmes_syst%C3%A8me%20prostitutionnel_VF.pdf

Pour l'anniversaire de la loi du 13 avril 2016 qui interdit l'achat d'acte sexuel, l'Observatoire national des violences faites aux femmes publie un état des lieux sur le système prostitutionnel en France. Les données présentées dans la publication sont issues notamment de chiffres enregistrés par les services de police et de gendarmerie (base des victimes des crimes et délits), la justice (statistiques pénales) et les associations (Service national d’accueil téléphonique de l’enfance en danger 119, associations d’aide aux victimes, etc.). Les points essentiels sont les suivants : -Plus de 9 victimes sur 10 sont des filles et des femmes -Près de la moitié des victimes de proxénétisme ou de recours délictuel à la prostitution sont mineures -8 mis en cause pour proxénétisme sur 10 sont des hommes -Entre 2017 et 2023, le nombre de condamnations définitives pour proxénétisme, proxénétisme aggravé, recours à la prostitution, recours à la prostitution aggravé et tenue d’un lieu de prostitution a doublé. La lettre propose également un focus sur les mineur·e·s victimes d’exploitation sexuelle. Il ressort que 13 % des condamnations pour des infractions relatives au système prostitutionnel inscrites au Casier judiciaire sont liées à des infractions sur mineur·e·s et que pour plus de 6 victimes sur 10, l’exploitation sexuelle a commencé avant l’âge de 15 ans.

Mission interministérielle pour la protection des femmes contre les violences et la lutte contre la traite des êtres humains (2024). " La prostitution en France.", Paris (Miprof).

https://www.egalite-femmes-hommes.gouv.fr/sites/efh/files/2024-05/Miprof-Observatoire-national-des-violences-faites-aux-femmes-Lettre-prostitution-2024_2.pdf

Cette lettre thématique de l’Observatoire national des violences faites aux femmes dresse, pour la première fois, un état des lieux des données policières, judiciaires et administratives sur le système prostitutionnel en France.

Mouvement du nid (2015). "Prostcost : Estimation du coût économique et social de la prostitution. Synthèse des résultats de l'étude". Clichy Mouvement du Nid ; Paris Psytel

https://prostcost.files.wordpress.com/2015/05/prostcost-synthc3a8se-ok.pdf

En 2014, la Commission européenne proposait aux Etats membres de l'Union européenne d'accroître leur richesse nationale en incluant le chiffre d'affaires de la prostitution dans le calcul de leur PIB. En France, l'Insee a refusé de se plier à cette demande, en expliquant que la prostitution s'apparentait moins à une "prestation de service librement consentie" qu'à une exploitation des personnes les plus précaires. Dans la même ligne, cette étude Prostcost menée par le Mouvement du nid et Psytel propose une estimation du double fardeau économique et social que le système prostitutionnel fait peser sur ses victimes et sur la société toute entière. Toutes les données mobilisées dans cette étude se trouve sur le site : www.prostcost.org.

Pohu, H., et al. (2022). "Promifrance : recherche-action pluridisciplinaire sur la prostitution des mineurs en France". Paris, Ministère chargé de la Santé.

https://solidarites-sante.gouv.fr/IMG/pdf/rapport-promifrance-cvm-janv2022.pdf

Ce colloque, organisé en présence de l’ancien secrétaire d’État en charge de l’enfance et des familles auprès du ministre des Solidarités et de la Santé, Adrien Taquet, rassemblait des acteurs des territoires impliqués dans le projet de recherche. Il a été l’occasion de présenter les principaux résultats de la recherche et de présenter des outils créés pour améliorer la prévention et le repérage des mineurs victimes de prostitution.

Schaffauser, T. (2014). "Les luttes des putes". Paris, La Fabrique éditions.

Pénaliser, abolir, verbaliser, réprimer?: tel est le bruit de fond commun aux discours sur «?les putes?», qu’ils émanent de députés, de féministes ou de maniaques de l’ordre moral et urbain. À contre-courant, ce livre défend l’idée de travail du sexe, idée scandaleuse entre toutes car elle implique une alliance entre le combat féministe, le combat ouvrier et celui des pauvres et des exclus. Se fondant sur son savoir historique et sur son expérience personnelle, Schaffauser dénonce les violences, décrypte les sollicitudes hypocrites et raconte l’histoire des luttes, en particulier la création du STRASS (Syndicat du travail sexuel), et ses rapports souvent conflictuels avec une «extrême gauche» confite dans la vertu. Un livre décapant et éclairant sur un sujet qu’il n’est plus possible d’éviter aujourd’hui. (4è de couv.)

Simonin, D. (2016). "Le « travail du sexe ». Genèses et usages d'une catégorie politique". Lyon, ENS

https://theses.hal.science/tel-01509444v1

La « prostitution » constitue actuellement un problème public en France, au croisement de luttes pour la réinsertion sociale ou la prévention sanitaire, contre les agressions ou pour l’obtention de droits. Différents collectifs se mobilisent pour imposer des définitions concurrentes entre deux pôles : l'abolition d'une « violence » et la reconnaissance d'un « travail ». De ces définitions découlent des revendications sur la réglementation de l'activité et la représentation du groupe. Partant de ce constat, cette thèse décrit la construction socio-historique du « travail sexuel » : la lutte d'un groupe minorisé pour s'approprier le pouvoir de définir le problème dont il fait l'objet. L'analyse part de la revendication de l'« invention » de la catégorie en 1978 aux États-Unis, jusqu'à l'adoption de la « loi visant à renforcer la lutte contre le système prostitutionnel » en avril 2016 en France. Elle se fonde d'une part sur un corpus documentaire pour retracer la diffusion et les usages de la catégorie, d'autre part sur une trentaine d'entretiens avec des personnes impliquées dans ces mobilisations pour restituer leurs parcours et leurs positions. La thèse montre d'abord des usages et des sens variés du « travail sexuel » selon les contextes, s'inscrivant notamment dans le mouvement féministe, la lutte contre le VIH/sida ou les débats sur l'immigration. Elle montre aussi une appropriation partielle du problème avec l'émergence d'un mouvement de « travailleur·se·s sexuel·le·s » au niveau international et en France. Elle montre enfin les difficultés de ce mouvement à imposer sa définition du « travail » et les déplacements qui en résultent des espaces et des objets de la lutte.

a l’etranger

Banerjee, S. (2025). "Sampling Strategies for Assessing Male Clients of Female Sex Workers in Public Health Research: A Compilation of Global Evidence." J Racial Ethn Health Disparities 29(1): 211-227.

Clients of Female Sex Workers (FSWs) are major bridge population in HIV transmission. Any research among them remains challenging because they are hidden within society. The objective of this review was to compile the global evidence on different sampling strategies used to access male clients of female sex workers for research purpose, the challenges faced during the sampling process and possible sources of bias. Original articles and reports published globally in last 10 years, in English language and those with full text freely available online were included in this scoping review. A comprehensive search was carried out among the electronic peer-reviewed literature database (Pubmed and Web of Science) using a pre-designed peer reviewed search strategy. Narrative synthesis was applied out across all such articles. A total of 36 articles were finally included in this review. The common sampling techniques used include convenience sampling, referral by FSWs/ pimp/brothel manager/clients, time location cluster sampling, use of virtual network, anonymous telephone survey, referred by clinicians of STI clinic etc. Overall response rate varied between 35 and 90%. Major challenges in participant recruitment included non-response, feasibility issue specially to cater non-brothel-based clients, safety issue for investigators, over-representation of clients with lower socio-economic status, higher refusal rate for known HIV positive clients to provide biological sample etc. As different sampling techniques have comparable response rate, it can be recommended that a pilot study should be carried out in local context to finalise appropriate participant recruitment technique for a given population.

Barros, A. B., et al. (2015). "Hard-to-reach populations of men who have sex with men and sex workers: a systematic review on sampling methods." Syst Rev 4: 141.

BACKGROUND: In public health, hard-to-reach populations are often recruited by non-probabilistic sampling methods that produce biased results. In order to overcome this, several sampling methods have been improved and developed in the last years. The aim of this systematic review was to identify all current methods used to survey most-at-risk populations of men who have sex with men and sex workers. The review also aimed to assess if there were any relations between the study populations and the sampling methods used to recruit them. Lastly, we wanted to assess if the number of publications originated in middle and low human development (MLHD) countries had been increasing in the last years. METHODS: A systematic review was conducted using electronic databases and a total of 268 published studies were included in the analysis. RESULTS: In this review, 11 recruitment methods were identified. Semi-probabilistic methods were used most commonly to survey men who have sex with men, and the use of the Internet was the method that gathered more respondents. We found that female sex workers were more frequently recruited through non-probabilistic methods than men who have sex with men (odds = 2.2; p < 0.05; confidence interval (CI) [1.1-4.2]). In the last 6 years, the number of studies based in middle and low human development countries increased more than the number of studies based in very high and high human development countries (odds = 2.5; p < 0.05; CI [1.3-4.9]). CONCLUSIONS: This systematic literature review identified 11 methods used to sample men who have sex with men and female sex workers. There is an association between the type of sampling method and the population being studied. The number of studies based in middle and low human development countries has increased in the last 6 years of this study.

Brooks, S. K., et al. (2023). "Struggling, Forgotten, and Under Pressure: A Scoping Review of Experiences of Sex Workers During the COVID-19 Pandemic." Arch Sex Behav 52(5): 1969-2010.

The COVID-19 pandemic profoundly affected physical, mental, and economic well-being across the globe and has disproportionately affected certain vulnerable groups. This paper provides a scoping review of literature on the impact of the COVID-19 pandemic on sex workers, published between December 2019 and December 2022. Six databases were systematically searched, identifying 1009 citations; 63 studies were included in the review. Thematic analysis revealed eight main themes: financial issues; exposure to harm; alternate ways of working; COVID-19 knowledge, protective behaviors, fear, and risk; well-being, mental health, and coping; access to support; access to health care; and the impact of COVID-19 on research with sex workers. COVID-associated restrictions led to reduced work and income, leaving many sex workers struggling to cover basic needs; additionally, government protections excluded those working in the informal economy. Fearing the loss of their already reduced number of clients, many felt compelled to compromise both prices and protective measures. Although some engaged in online sex work, this raised concerns about visibility and was impossible for those without technological access or skills. Many feared COVID-19, but felt pressure to continue working, often with clients who refused to wear masks or share exposure history. Other negative impacts on well-being related to the pandemic included reduced access to financial support or health care. Marginalized populations (and especially those in professions which require close contact like sex workers) need further support and capacity-building within the community to recover from the impact of COVID-19.

Brussa, L. et Munk, V. (2010). "Vulnerabilities and rights of migrant sex workers in Europe." HIV AIDS Policy Law Rev 15(1): 61-62.

In recent years, Europe has witnessed a rise in the number of migrant sex workers, in part because of increased mobility for citizens of European Union member states. However, migrant sex workers find themselves in a highly vulnerable position in regard to having their rights respected and accessing HIV prevention services. In this article, based on a presentation at AIDS 2010, Licia Brussa and Veronica Munk outline the current situation of migrant sex workers in Europe and the steps that need to be taken to ensure that their rights are respected.

Carrillo, S. A., et al. (2020). "Implementing Respondent-Driven Sampling to Recruit Women Who Exchange Sex in New York City: Factors Associated with Recruitment and Lessons Learned." AIDS Behav 24(2): 580-591.

Respondent-driven sampling (RDS) relies on productive peer recruitment to capture hidden populations. Domestic studies have identified characteristics of productive recruitment among RDS samples of men who have sex with men and persons who use drugs, but not of women who exchange sex, a group vulnerable to HIV infection. We examined sociodemographic-, behavioral-, exchange-sex-, and protocol-related factors associated with recruitment among seeds (n = 25) and peers (n = 297) in the 2016 New York City National HIV Behavioral Surveillance Study cycle focused on women who exchange sex. Recruiter productivity was significantly associated with not having been recently incarcerated, lower rate of HIV testing, and larger exchange sex networks among seeds, and with HIV-prevention services usage among peers. We describe challenges and lessons learned from implementing RDS in this population. Our study identifies seed characteristics and protocol improvements researchers can utilize when implementing future RDS studies among women who exchange sex.

Cunningham, S. et Shah, M. (2018). "The Oxford Handbook of the Economics of Prostitution". Oxford, Oxford University Press.

Prostitution is one of the least understood occupations but appears to have all the features of traditional markets: prices, supply and demand considerations, variety in the organizational structure, and policy relevance. These are keystones of economics analysis. Greater access to data has enabled economists to build better theories and gain a better understanding of the organization of sex market. The Oxford Handbook of the Economics of Prostitution is a comprehensive economic analysis of prostitution. It examines how prostitution markets are organized across space and time, the role of technology in shaping labor supply and demand, the intersection of prostitution with trafficking, and the optimal use of law enforcement. Among the issues addressed are the determination of sex worker prices, sexual assault and sex workers, bargaining, and STD transmission in sex work. What makes the material unique is its explicit focus on economics as the primary methodology for organizing our understanding of prostitution. It sheds light on underground markets, labor economics, risky behaviors, marriage, and gender.

Langenbach, B. P., et al. (2023). "Attitudes towards sex workers: a nationwide cross-sectional survey among German healthcare providers." Front Public Health 11.

Background Worldwide, sex workers face stigmatization and discrimination, also within healthcare. Only few studies on healthcare providers' attitudes towards care of sex workers have been performed. This study assessed attitudes and knowledge of healthcare providers in Germany towards sex workers and their specific health risks. Methods German healthcare professionals and medical students were invited to participate in a nationwide cross-sectional study in 2022. The online survey used a German translation of the "Attitudes towards Prostitutes and Prostitution Scale" by Levin and Peled for assessment of attitudes towards sex work and workers, together with prevalence estimates of common mental and physical disorders. Results A total of 469 questionnaires were included into analysis. Older participants tended to regard sex work as less of a choice (p < 0.004) and sex workers as more victimized (p < 0.001). The frequency of professional contact to sex workers neither affected the perception of sex workers' status as victims vs. independent individuals, nor the perceived moral status. Moreover, healthcare professionals overestimated the prevalence of various disorders which was influenced by participants' attitudes towards sex workers. Discussion A comparison to a recent Allensbach survey demonstrated similar attitudes of healthcare providers and the general population towards sex workers. Our results suggest that German healthcare professionals are not free of prejudices against sex workers, as has been shown for other marginalized groups in society. Instead, they seem to be influenced by personal opinion rather than by objective facts which they should have acquired during their professional education. Future interventions (e.g., better training regarding marginal societal groups) are necessary to encounter these issues in order to improve healthcare for sex workers.

Oliveira, A., et al. (2023). "Understanding the Impact of EU Prostitution Policies on Sex Workers: A Mixed Study Systematic Review." Sexuality Research and Social Policy 20(4): 1448-1468.

https://doi.org/10.1007/s13178-023-00814-2

There is a growing interest in legislation and policies regarding sex work in the European Union and a debate between two opposite perspectives: prostitution is a form of gender violence or a work lacking legal and social recognition. This review aims to develop an integrative synthesis of literature regarding the impact of prostitution policies on sex workers’ health, safety, and living and working conditions across EU member states.

Stenersen, M., et al. (2025). "Sex Work Patterns Among Transgender and Gender Diverse People: A Latent Class Analysis." journal of homosexuality 72(11): 2134-2152.

Sex work is a diverse profession encompassing a broad range of people, and services. Though overrepresented in sex work communities, transgender and gender diverse (TGD) individuals are underrepresented in sex work literature. Further, sex work literature continues to underrepresent the heterogeneity evident in the sex work community and the practices that occur within it. The present study utilized data from the 2015 United States Transgender Survey (USTS) to conduct a latent class analysis (LCA) to identify patterns of different types of sex work among TGD adults (N = 2,153) and understand the demographic characteristics associated with engagement in different types of sex work. Conceptual and statistical fit indices indicated an ideal 5-class model. Classes include (1) High Online Primary, (2) Low Online Primary, (3) Varied Sex Work, (4) Erotic Dancer, and (5) Street Primary. Results also revealed multiple differences in class membership based on demographic variables including gender identity, race/ethnicity, and sexual orientation. For example, individuals in Class 5 were significantly more likely to report no income, or income below $10,000, compared to all other classes. Taken together, the current findings highlight the varied and diverse settings, activities, and circumstances of TGD sex workers. Findings also point to a continued need to acknowledge, account for, and value the voices of sex workers across the industry when conducting research, health services, and advocacy.

Wesson, P., et al. (2017). "Theoretical and Empirical Comparisons of Methods to Estimate the Size of Hard-to-Reach Populations: A Systematic Review." AIDS Behav 21(7): 2188-2206.

Worldwide, the HIV epidemic is concentrated among hidden populations (i.e., female sex workers, men who have sex with men, and people who inject drugs). To understand the true scope and scale of the HIV epidemic, estimates of the sizes of these populations are needed. Various methods are available to enumerate hidden populations, but the degree of agreement between these methods has not been formally evaluated. We systematically reviewed the peer-reviewed literature to assess the extent to which different population size estimation methods provide the same estimate of a target population. Of the 341 studies identified from our search, 25 met our eligibility criteria. Twenty-one unique methods were documented. The service multiplier method was the most common in the review. Eighty target populations were estimated, covering 16 countries. We observed variable population size estimates, with little agreement between methods. We note trends in the relative performance of individual methods.

Etat de santé physique et mentale des travailleurs du sexe

Quelques Revues de littérature

Aldridge, R. W., et al. (2018). "Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis." Acta Psychiatr Scand 391(10117): 241-250.

BACKGROUND: Inclusion health focuses on people in extremely poor health due to poverty, marginalisation, and multimorbidity. We aimed to review morbidity and mortality data on four overlapping populations who experience considerable social exclusion: homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library for studies published between Jan 1, 2005, and Oct 1, 2015. We included only systematic reviews, meta-analyses, interventional studies, and observational studies that had morbidity and mortality outcomes, were published in English, from high-income countries, and were done in populations with a history of homelessness, imprisonment, sex work, or substance use disorder (excluding cannabis and alcohol use). Studies with only perinatal outcomes and studies of individuals with a specific health condition or those recruited from intensive care or high dependency hospital units were excluded. We screened studies using systematic review software and extracted data from published reports. Primary outcomes were measures of morbidity (prevalence or incidence) and mortality (standardised mortality ratios [SMRs] and mortality rates). Summary estimates were calculated using a random effects model. FINDINGS: Our search identified 7946 articles, of which 337 studies were included for analysis. All-cause standardised mortality ratios were significantly increased in 91 (99%) of 92 extracted datapoints and were 11·86 (95% CI 10·42-13·30; I(2)=94·1%) in female individuals and 7·88 (7·03-8·74; I(2)=99·1%) in men. Summary SMR estimates for the International Classification of Diseases disease categories with two or more included datapoints were highest for deaths due to injury, poisoning, and other external causes, in both men (7·89; 95% CI 6·40-9·37; I(2)=98·1%) and women (18·72; 13·73-23·71; I(2)=91·5%). Disease prevalence was consistently raised across the following categories: infections (eg, highest reported was 90% for hepatitis C, 67 [65%] of 103 individuals for hepatitis B, and 133 [51%] of 263 individuals for latent tuberculosis infection), mental health (eg, highest reported was 9 [4%] of 227 individuals for schizophrenia), cardiovascular conditions (eg, highest reported was 32 [13%] of 247 individuals for coronary heart disease), and respiratory conditions (eg, highest reported was 9 [26%] of 35 individuals for asthma). INTERPRETATION: Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised. FUNDING: Wellcome Trust, National Institute for Health Research, NHS England, NHS Research Scotland Scottish Senior Clinical Fellowship, Medical Research Council, Chief Scientist Office, and the Central and North West London NHS Trust.

Báez-Martínez, S. et Gallur-Santorum, S. (2026). "Social Determinants of Health of Racialized Male Sex Workers: Scoping Literature Review."  13(1): 167-187.

BACKGROUND: This study is a scoping review that maps existing scientific literature on the health needs of racialized men in sex work, framed within the Social Determinants of Health model. OBJECTIVES: The review aims to identify and analyze health vulnerabilities among this population, focusing on how various social determinants impact their health. ELIGIBILITY CRITERIA: Studies published in the last 5 years, in English or Spanish, open-access, focused on male sex workers, without specific geographic limitations. SOURCES OF EVIDENCE: Systematic searches were conducted in Scopus, Redalyc, Google Scholar, and PubMed. CHARTING METHODS: Using search queries "male sex work" AND health; "male sex work" AND race AND health; "male prostitution" AND race AND health, a total of 2,643 records were retrieved and screened. After applying inclusion and exclusion criteria, 32 studies were selected for review. RESULTS: Analysis based on the Dahlgren-Whitehead Social Determinants of Health model reveals that racialized male sex workers experience health vulnerabilities primarily influenced by individual and proximal determinants, with less emphasis on intermediate and distal factors such as social networks and community support. CONCLUSIONS: These findings highlight significant health disparities affecting racialized MSWs, underscoring the need for a structural and comprehensive approach to address these disparities. This study advocates moving beyond a blame-oriented, moralistic view of individual behaviors in traditional epidemiology, focusing instead on social and structural interventions to improve sexual health outcomes for this marginalized group.

Creasy, S. L., et al. (2025). "Exploring the impact of stigma on the health of inclusion health groups: a qualitative scoping review and critical analysis." Patient Prefer Adherence 26(1): 24.

BACKGROUND: Health inequalities have widened globally over the past decade, disproportionately affecting socially excluded populations broadly defined as 'inclusion health groups'. These groups, including people experiencing homelessness, migrants, sex workers, people with substance use disorders, victims of modern slavery, and those in contact with the justice system, face compounded negative health consequences often exacerbated by stigma. This scoping review aimed to examine qualitative literature exploring how stigma impacts the physical and mental health of inclusion health groups. Building on the work of Link and Phelan, Tyler, and Hatzenbuehler, this review situates stigma as a relational and structural process that operates through power, policy, and institutions to shape health outcomes among inclusion health populations. METHODS: The review focused on identifying how stigma is conceptualised across inclusion health groups and how it functions as a shared mechanism influencing health, health behaviour, and access to care. Following the PRISMA-ScR framework, we searched Scopus, OVID Medline, and PsycINFO for qualitative studies published between 01/01/2015 and 15/03/2025. Titles, abstracts, and full texts were screened, resulting in 28 articles included for analysis. RESULTS: Stigma was consistently identified as a barrier to healthcare access, leading to delayed treatment and worsening physical and mental health outcomes for inclusion health groups. The literature disproportionately focuses on people who use drugs, with limited research addressing other inclusion health groups, highlighting significant gaps in the field. Furthermore, existing conceptualisations of stigma frequently neglect its structural determinants, risking reinforcement of individualised explanations for poor health rather than addressing systemic drivers of inequality. CONCLUSIONS: This review demonstrates that stigma contributes to health inequalities by limiting healthcare access and shaping negative health outcomes. There is an urgent need for research that investigates stigma's long-term health effects and moves beyond individual-level interventions to address broader structural forces perpetuating health inequalities. Future work should more explicitly engage with the concept of structural and political stigma, recognising that public health research must interrogate the upstream determinants, such as policy, governance, and social organisation, that sustain exclusion and health inequity.

Fitzgerald-Husek, A., et al. (2017). "Measuring stigma affecting sex workers (SW) and men who have sex with men (MSM): A systematic review." PLoS One 12(11): e0188393.

BACKGROUND: Stigma involves discrediting a person or group based on a perceived attribute, behaviour or reputation associated with them. Sex workers (SW) and men who have sex with men (MSM) are key populations who are often at increased risk for the acquisition and transmission of HIV and who are affected by stigma that can negatively impact their health and well-being. Although stigma was included as an indicator in the US National HIV/AIDS Strategic Plan and there have been consultations focused on adding a stigma indicator within PEPFAR and the Global Fund in relation to potentiating HIV risks among key populations, there remains limited consensus on the appropriate measurement of SW- or MSM-associated stigma. Consequently, this systematic review summarizes studies using quantitative, qualitative, or mixed methods approaches to measure stigma affecting sex workers and men who have sex with men. METHODS AND FINDINGS: This systematic review included English, French, and Spanish peer-reviewed research of any study design measuring SW- or MSM-associated stigma. Articles were published from January 1, 2004 to March 26, 2014 in PsycINFO, PubMed, EMBASE, CINAHL Plus, Global Health, and World Health Organization Global Health Library Regional Indexes. Of the 541 articles reviewed, the majority measured stigma toward MSM (over 97%), were conducted in North America, used quantitative methods, and focused on internalized stigma. CONCLUSIONS: With the inclusion of addressing stigma in several domestic and international HIV strategies, there is a need to ensure the use of validated metrics for stigma. The field to date has completed limited measurement of stigma affecting sex workers, and limited measurement of stigma affecting MSM outside of higher income settings. Moving forward requires a concerted effort integrating validated metrics of stigma into health-related surveys and programs for key populations.

Kalinowski, O., et al. (2024). "Prevalence, risk and resilience factors of mental health conditions among female sex workers: a systematic review and meta-analysis." J Epidemiol Community Health 12: 1455999.

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.

Love, R. (2015). "Street Level Prostitution: A Systematic Literature Review." Issues Ment Health Nurs 36(8): 568-577.

The aim of this study was to synthesize research on female street level prostitutes for application in mental health practice and identification of future research needs. The data were from reports conducted in Westernized countries on female street level prostitutes between the years 2000 and 2014. Street level prostitutes are at high risk for HIV/STIs, chronic and acute physical/mental health problems, and violence, but there is a paucity of research on resilience and coping skills. We conclude that street level prostitutes suffer severe health disparities, yet they do not seek health care on a consistent basis. It is important for mental healthcare providers to offer women a safe, non-judgmental environment while providing assessment and referral. Future research on mental health consequences as well as resilience and coping skills would support effective interventions that address the women holistically.

Martín-Romo, L., et al. (2023). "Invisible and stigmatized: A systematic review of mental health and risk factors among sex workers." Acta Psychiatr Scand 148(3): 255-264.

INTRODUCTION: Sex work is a common phenomenon, but socially invisible and stigmatized. Due to exposure to work-related risks, sex workers (SWs) are vulnerable to developing health problems. However, little attention has been paid to their mental health. The purpose of this systematic review was to synthesize the existing literature on mental health and to explore risk factors related to psychopathology in sex workers. METHODS: A systematic review (CRD42021268990) was conducted on the Web of Science, PubMed, Scopus, and PsycInfo for peer reviewer papers published between 2010 and 2022. The Newcastle-Ottawa Scale (NOS) was used to examine the quality of the studies. Of the 527 studies identified, 30 met the inclusion criteria. RESULTS: Mental health problems were prevalent among sex workers. Depression was the most common mental health problem; however, other psychological problems were also high, including anxiety, substance abuse, and suicidal ideation. Sex workers are exposed to numerous work-related risks, including violence and high-risk sexual behaviors. Despite the high prevalence of mental health problems, SWs often encounter significant barriers to accessing healthcare services. CONCLUSION: These results suggest the need to focus on preventive measures to promote psychological well-being among sex workers.

McCann, J. et Crawford, G. (2021). "Sex Worker Health Outcomes in High-Income Countries of Varied Regulatory Environments: A Systematic Review."  18(8).

There is significant debate regarding the regulation of the sex industry, with a complex range of cultural, political and social factors influencing regulatory models which vary considerably between and within countries. This systematic review examined the available evidence on the relationship between different approaches to sex industry regulation in high-income countries, and associated effects on sex worker health status. Objectives included identification of sex worker health outcomes, including sexual health, substance use and experience of stigma and violence. A search was performed electronically in eight scholarly databases which yielded 95 articles which met the criteria for inclusion. Findings suggested that sex workers in legalised and decriminalized countries demonstrated greater health outcomes, including awareness of health conditions and risk factors.

McCarty, C., et al. (2019). "Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries." AIDS Care 19(1): 212.

BACKGROUND: Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries. METHODS: We searched for publications over the last decade (January 2005-March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited. RESULTS: Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted. CONCLUSIONS: The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

Mehta, V., et al. (2025). "Oral Health Status of Sex Workers Across the Globe: A Systematic Review." Spec Care Dentist 45(3): e70068.

INTRODUCTION: Despite the high vulnerabilities of sex workers to poor oral health, there is a substantial global gap in comprehensive evidence regarding their oral health status, reflecting a broader neglect of their oral healthcare needs in public health discourse. In light of this, our systematic review seeks to synthesize and consolidate current global research on the oral health status of sex workers, highlighting the prevalence of oral disorders among the group. METHODS: A search method was developed to find papers indexed in three electronic databases. Studies addressing the oral health of adult sex workers, whether female, male, or LGBTQ+, were considered. The methodological quality of the studies was evaluated using the Newcastle-Ottawa Scale (NOS). The findings from the included research were synthesized and provided in a narrative format. RESULTS: Out of 4185 studies, 11 were included in the analysis. Four studies found that the prevalence of oral lesions among sex workers ranged between 8.14% and 81.35%. Oral sexually transmitted infections (OSTIs) were identified, including human papillomavirus (HPV), chlamydia trachomatis, and Neisseria gonorrhoeae. Furthermore, half of the sex workers were reported to use substances, including alcohol, cigarettes, and tobacco. A high frequency of dental cavities and poor periodontal health was also reported. CONCLUSION: The most prevalent oral health conditions among sex workers include oral lesions, dental caries, periodontitis, and oral STIs. Substance abuse, notably smoking in various forms, is also extremely widespread. Designing and implementing tailored health interventions addressing substance abuse, stress management, good oral health, and hygiene practices, as well as training dental professionals on the use of inclusive language in clinical settings, are critical to encouraging sex workers to seek help for oral health issues, thereby improving their oral health outcomes.

Mühlen, A., et al. (2023). "[Mental Health Situation of Sex Workers in Europe: a Scoping Review]." J Prim Care Community Health 85(6): 561-567.

BACKGROUND: Due to the nature of their activity, sex workers often experience a lack of acceptance and stigmatization in society. This results in numerous exclusion mechanisms and stress factors, which might be associated with an increased vulnerability to mental illness. OBJECTIVE: To identify studies on the mental health situation of sex workers in Europe. METHODOLOGY: A scoping review identified n=12 relevant studies published from 1990 onwards in the scientific databases LIVIVO, BASE, PubMed and PSYNDEX. RESULTS: At least one mental disorder was reported in 56-75% of sex worker*respondents. Depression, substance use, suicidality, and post-traumatic stress were particularly common among respondents. The results show that sex workers are vulnerable to psychological stressors and illnesses. Comprehensive psychosocial support and counseling is indicated, taking into consideration the different work contexts and life situations.

Millan-Alanis, J. M. et Carranza-Navarro, F. (2021). "Prevalence of suicidality, depression, post-traumatic stress disorder, and anxiety among female sex workers: a systematic review and meta-analysis."  24(6): 867-879.

The purpose was to assess prevalence of suicidality, depression, post-traumatic stress disorder (PTSD), and anxiety among female sex workers (FSW). A systematic review and meta-analysis was performed. Search strategy was performed in MEDLINE, Scopus, Web of Science, EMBASE, Ovid and Cochrane Central Database from inception until March 2020. Considered for inclusion were cross-sectional studies performed on FSW that assessed prevalence of any of the following: suicide attempt or suicidal ideation, depression, PTSD, or anxiety. Five reviewers, independently and in duplicate, selected all eligible articles in an abstract and full-text screening phase and, moreover, extracted information from each study. A binomial-normal generalized linear mixed model was employed to estimate prevalence of the conditions. From 8035 studies yielded in the search strategy, 55 were included for analysis. The overall prevalence of suicidal ideation and attempt was 27% (95% C.I. 18-39%) and 20% (95% C.I. 13-28%), respectively. Furthermore, overall prevalence of depression and PTSD was 44% (95% C.I. 35-54%) and 29% (95% C.I. 18-44%), respectively. Eleven studies were classified as high quality. Findings indicate that there is an overall high prevalence of suicidality, depression, and PTSD among FSW. Development of accessible large-scale interventions that assess mental health among this population remains critical.

Rocillo Aréchaga, E. P., et al. (2025). "Health Status of North African Adolescent and Young Adult Migrants in Europe: a Scoping Review."

More than five million people from North Africa (NA) lived in Europe in 2019, including youth characterized by intense trans-border mobility, precarious living conditions and high-risk behaviours such as substance use, prostitution and illegal activities. This young population challenges health professionals and health service's ability to deliver medical care. The health literature about them remains scarce. This scoping review aims to map the existing knowledge regarding the health status of adolescent and young adult migrants from NA in Europe, the health services available to address their needs, and their access and use of these services. This scoping review followed the Arksey and O´Malley process and was based on the Population-Concept-Context framework. Six databases (CINAHL, Cochrane, Embase, PubMed, PsycINFO and Web of Science) were consulted for peer-reviewed articles and non-indexed reports. References of selected articles were systematically tracked. Initial search returned 5540 articles, 13 of which met the criteria for final inclusion. They originated from Spain, France and Germany. All records included were observational. Nine included only males and ten focused on unaccompanied minors. All studies explored aspects related to the health status of participants. Five explored aspects related to general health, seven to infectious diseases, six to mental health including substance use, four to oral health, and three to nutritional status. Two studies explored aspects related to the provision of care and related cultural elements. Evidence about the health status, access to services and health service provision of North African adolescent and young adult migrants in Europe is very limited, including important gaps about females and young adults, as well as about healthcare programs and use of services. Further research is needed to enhance a comprehensive, complex and reflective understanding of this population. Research design should emphasize gender perspective, include methodologies adapted to hard-to-reach populations and grounded into international collaboration.

Stengaard, A. R., et al. (2021). "HIV seroprevalence in five key populations in Europe: a systematic literature review, 2009 to 2019." Euro Surveill 26(47).

Background In Europe, HIV disproportionately affects men who have sex with men (MSM), people who inject drugs (PWID), prisoners, sex workers, and transgender people. Epidemiological data are primarily available from national HIV case surveillance systems that rarely capture information on sex work, gender identity or imprisonment. Surveillance of HIV prevalence in key populations often occurs as independent studies with no established mechanism for collating such information at the European level. Aim We assessed HIV prevalence in MSM, PWID, prisoners, sex workers, and transgender people in the 30 European Union/European Economic Area countries and the United Kingdom. Methods We conducted a systematic literature review of peer-reviewed studies published during 2009-19, by searching PubMed, Embase and the Cochrane Library. Data are presented in forest plots by country, as simple prevalence or pooled across multiple studies. Results Eighty-seven country- and population-specific studies were identified from 23 countries. The highest number of studies, and the largest variation in HIV prevalence, were identified for MSM, ranging from 2.4-29.0% (19 countries) and PWID, from 0.0-59.5% (13 countries). Prevalence ranged from 0.0-15.6% in prisoners (nine countries), 1.1-8.5% in sex workers (five countries) and was 10.9% in transgender people (one country). Individuals belonging to several key population groups had higher prevalence. Conclusion This review demonstrates that HIV prevalence is highly diverse across population groups and countries. People belonging to multiple key population groups are particularly vulnerable; however, more studies are needed, particularly for sex workers, transgender people and people with multiple risks.

Tweed, E. J. (2021). "Health of people experiencing co-occurring homelessness, imprisonment, substance use, sex work and/or severe mental illness in high-income countries: a systematic review and meta-analysis." J Adv Nurs 75(10): 1010-1018.

BACKGROUND: People affected by homelessness, imprisonment, substance use, sex work or severe mental illness experience substantial excess ill health and premature death. Though these experiences often co-occur, health outcomes associated with their overlap have not previously been reviewed. We synthesised existing evidence on mortality, morbidity, self-rated health and quality of life among people affected by more than one of these experiences. METHODS: In this systematic review and meta-analysis, we searched Medline, Embase, and PsycINFO for peer-reviewed English-language observational studies from high-income countries published between 1 January 1998 and 11 June 2018. Two authors undertook independent screening, with risk of bias assessed using a modified Newcastle-Ottawa Scale. Findings were summarised by narrative synthesis and random-effect meta-analysis. RESULTS: From 15 976 citations, 2517 studies underwent full-text screening, and 444 were included. The most common exposure combinations were imprisonment/substance use (31% of data points) and severe mental illness/substance use (27%); only 1% reported outcomes associated with more than two exposures. Infections were the most common outcomes studied, with blood-borne viruses accounting for 31% of all data points. Multiple exposures were associated with poorer outcomes in 80% of data points included (sign test for effect direction, p<0.001). Meta-analysis suggested increased all-cause mortality among people with multiple versus fewer exposures (HR: 1.57 and 95% CI: 1.38 to 1.77), though heterogeneity was high. CONCLUSION: People affected by multiple exclusionary processes experience profound health inequalities, though there are important gaps in the research landscape. Addressing the health needs of these populations is likely to require co-ordinated action across multiple sectors, such as healthcare, criminal justice, drug treatment, housing and social security. PROSPERO REGISTRATION NUMBER: CRD42018097189.

Wu, J., et al. (2021). "Worldwide burden of genital human papillomavirus infection in female sex workers: a systematic review and meta-analysis." Int J Epidemiol 50(2): 527-537.

BACKGROUND: Although female sex workers (FSWs) have long been identified as a key human papillomavirus (HPV)-affected population, the burden and scope of their disproportionate risk for HPV infection have not been systematically estimated. We therefore aimed to estimate the prevalence of HPV and the distribution of HPV types in FSWs at the country, regional and global levels. METHODS: We searched the PubMed, Embase, SCOPUS, EBSCO, ProQuest, Cochrane Library and Web of Science databases for articles published between 1 January 1990 and 31 June 2019. Studies of genital HPV prevalence in FSWs, or with sufficient data (e.g. adequate number of HPV-positive cases and sample size) to compute prevalence rates in FSWs, were included in this systematic review. The meta-analysis was completed using the random effects model. RESULTS: We ultimately identified 107 studies in 45 countries or regions with sufficient data to calculate HPV prevalence in FSWs. The pooled global HPV prevalence among FSWs was 39.5% (95% CI 35.3, 43.9%), with notable variations by WHO region and country. Globally, the five most common HPV types in FSWs were HPV16 (9.0%), HPV 52 (8.3%), HPV89 (7.0%), HPV58 (6.2%), and HPV53 (5.3%). CONCLUSIONS: Our findings suggest that FSWs are disproportionately affected by HPV, which is more pronounced in the Western Pacific and African regions, and are therefore in need of prevention, treatment and care services.

EN France

Aubin, C., et al. (2012). "Prostitutions : les enjeux sanitaires". Paris, I.G.A.S.

[BDSP. Notice produite par MIN-SANTE nkR0x7so. Diffusion soumise à autorisation]. L'IGAS s'est intéressée, dans le cadre de son programme d'activité, aux enjeux sanitaires liés à la prostitution. La mission rappelle tout d'abord que ce terme recouvre des réalités diverses, contrastées, en constante évolution, induisant donc des problèmes et des besoins variables en termes de santé. Dans le cadre de la prévention, du suivi médical et des soins des personnes qui se prostituent, elle appelle à une véritable reconnaissance et une effectivité de leurs droits. Elle constate toute la pertinence du modèle d'intervention des milieux associatifs en direction des personnes qui se prostituent dans la rue, fondé sur les démarches "d'aller vers" et "d'accueil à bas seuil", soulignant à ce sujet la nécessité d'élargir et de conforter ces actions. Compte tenu de la difficulté d'appréhender toutes les formes de prostitution, dont certaines, moins visibles, nécessitent de développer des modes d'intervention adaptés (indoor, Internet), la mission recommande une approche pragmatique, transversale et coordonnée visant à organiser et faire converger les efforts de tous les acteurs : améliorer la connaissance concernant les différentes formes de prostitutions ; mieux prendre en compte les problématiques prostitutionnelles dans les différentes politiques menées ; conforter et développer l'approche préventive ; apporter une attention particulière aux publics les plus fragiles.

Balhan L, Annequin M, Faye A, et al.  (2025). "Qui sont les femmes transgenres vivant avec le VIH en France ? Caractéristiques sociodémographiques, de transition et de prise en charge. Résultats de l’enquête ANRS-Trans&VIH. " Bull Epidemiol Hebd. 2025;(19-20):364-72.

https://beh.santepubliquefrance.fr/beh/2025/19-20/2025_19-20_2.html

Cet article vise à décrire les caractéristiques sociodémographiques, de transition et de prise en charge des femmes transgenres vivant avec le VIH (FTVIH) suivies à l’hôpital en France. Il décrit également les caractéristiques de la migration des femmes trans nées à l’étranger.

Les données présentées sont issues de l’enquête ANRS-Trans&VIH, une enquête nationale, transversale, rétrospective et une recherche communautaire sur les FTVIH bénéficiant d’une prise en charge du VIH dans des unités hospitalières en France. L’enquête a été réalisée entre 2020 et 2022. Les caractéristiques sociodémographiques, de transition et de vie avec le VIH ont été comparées entre les femmes transgenres de nationalité française et de nationalité étrangère au moment de l’enquête, avec des tests de Chi2 et des tests de Wilcoxon.

Catin, M. (2024). "Le TDS : une stratégie de survie pour les personnes neuroatypiques." Journal de droit de la santé et de l' assurance maladie(40): 43-48.

https://institutdroitsante.fr/publications/publications-ids/revues-livres/journal-de-la-sante-et-de-lassurance-maladie-jdsam/jdsam-n40-juillet-2024

Les travailleurs et travailleuses du sexe font face à des difficultés d’accès aux soins mentaux qui leur sont propres. D’abord, les personnes exerçant cette activité cumulent bien souvent les facteurs de vulnérabilité, comme l’absence de papiers, une neuroatypie, ou encore, un contexte économique et familial déséquilibré. Au quotidien, ces personnes subissent également les biais imposés par la société et les pouvoirs publics quant à leur conception du travail du sexe, le considérant comme dégradant et aggravant des pathologies mentales, alors que le travail du sexe est souvent considéré par les personnes qui l’exercent comme un exutoire.

Godefroy, J. P. et Jouanno, C. (2013). "Rapport d'information sur la situation sanitaire et sociale des personnes prostituées". Paris Sénat

http://www.senat.fr/rap/r13-046/r13-0461.pdf

La commission des affaires sociales du Sénat a confié, en début d'année, à Chantal Jouanno et Jean-Pierre Godefroy, une mission sur la situation sanitaire et sociale des personnes prostituées afin de prendre la mesure des enjeux sociaux de la prostitution, dont le visage a fortement évolué ces vingt dernières années en raison de l'influence grandissante des réseaux de proxénétisme et de traite. La mission dresse le constat d'une grande vulnérabilité sanitaire des personnes prostituées, qui se caractérise par un état de santé globalement très préoccupant et un recours aux soins largement insuffisant. Alors que ces personnes bénéficient théoriquement des mêmes droits sociaux que les autres citoyens, elles n'accèdent, dans les faits, que très difficilement aux dispositifs sociaux. La situation est particulièrement inquiétante s'agissant des personnes prostituées étrangères exerçant sous l'emprise des réseaux. Dans ce contexte, la mission est convaincue que, sans présager des éventuelles évolutions du cadre légal de la prostitution, il est d'ores et déjà possible de tracer les pistes d'un accompagnement social global des personnes prostituées, qui permette de leur offrir des alternatives crédibles en termes de garantie de revenus, d'hébergement, de formation professionnelle et de suivi psychologique. Il est urgent d'agir et d'inverser le regard que porte la société sur ces personnes : c'est tout l'enjeu des 34 propositions formulées par la mission (résumé de l'éditeur).

Guillemaut, F. et Schutz-Samson, M. (2009). "Enquête sur la prostitution en Guadeloupe, pour améliorer la prévention." La Santé de l'homme(403): 24-25.

Haute Autorité de Santé, H. A. S. (2016). "État de santé des personnes en situation de prostitution et des travailleurs du sexe et identification des facteurs de vulnérabilité sanitaire". Saint-Denis La Plaine

https://www.has-sante.fr/jcms/c_2615057/fr/etat-de-sante-des-personnes-en-situation-de-prostitution-et-des-travailleurs-du-sexe-et-identification-des-facteurs-de-vulnerabilite-sanitaire

En réponse à la saisine qui lui a été adressée par la Direction générale de la santé, la HAS a réalisé un état des lieux des connaissances sur la situation sanitaire des personnes en situation de prostitution et sur les facteurs de vulnérabilité sanitaire de ces personnes. Ce travail s’inscrit dans le cadre d’éventuelles modifications réglementaires futures, susceptibles d’avoir un impact sur la santé des personnes en situation de prostitution, et ont pour vocation de servir de socle de connaissances à une politique de réduction des risques.   Résumé des recommandations de bonne pratique validées sur les problématiques sanitaires vis-à-vis desquelles les personnes en situation de prostitution/tds sont particulièrement exposées Objectif et méthode Il est proposé dans le cadre de cette annexe de synthétiser l’ensemble des recommandations de bonne pratique françaises sur l’ensemble des infections sexuellement transmissibles et sur les autres pathologies qui affectent spécifiquement cette population afin de contribuer concrètement à l’amélioration de l’information des personnes sur les pratiques de prévention, les traitements et les parcours de soins en vue de favoriser leur prise en charge globale. Ces synthèses ont été conçues à destination des associations de patients et d’usagers, ainsi que des associations et institutions impliquées dans l’accompagnement des personnes en situation de prostitution/tds qui sont les principaux acteurs de prévention auprès de ces populations, voire de premier recours lorsque les personnes ont un accès limité au système de santé. Ces acteurs ne disposent pas nécessairement d’une formation médicale. Il est donc est utile qu’ils disposent d’un certain nombre d’informations nécessaires pour diffuser des messages de prévention et pour répondre à leurs questions et pour les orienter vers le système de soins lorsque ces personnes leur font part de certains symptômes. De même, il est utile qu’ils disposent d’informations sur les traitements et les parcours de soins afin de favoriser un accès aux soins adéquat, l’observance des traitements et la prise en charge globale des personnes. L’opportunité d’inclure ces synthèses dans les annexes du présent document a été confirmée par les conclusions de la revue de la littérature sur l’état de santé des personnes en situation de prostitution/tds. En effet, il est apparu que ces personnes étaient davantage exposées que les individus en population générale aux risques d’infections sexuellement transmissibles moins connues que le VIH/Sida ou que les hépatites, telles que les infections à Chlamydia trachomatis, gonocoque et papillomavirus, ainsi que vis-à-vis de certains troubles (vaginose, candidose, inflammation pelvienne).Ces éléments de synthèse n’ont en revanche pas été conçus pour être utilisés par les professionnels de santé comme une check-list ou comme un référentiel d’aide à la consultation lorsqu’ils accueillent des personnes en situation de prostitution/tds. Cette annexe se limite à résumer l’ensemble des recommandations valides disponibles en France, tandis qu’il existe des problématiques sanitaires, qui affectent spécifiquement les personnes en situation de prostitution/tds pour lesquelles il n’existe pas ou peu de recommandations. C’est le cas notamment de la prise en charge des personnes victimes de violences (traumatismes et souffrances psychiques). La revue de la littérature n’a par ailleurs pas permis d’identifier de recommandations sur l’ensemble des troubles uro-gynécologiques qui sont susceptibles d’affecter les personnes en situation de prostitution /tds. Enfin les professionnels de santé qui participaient au groupe de parties prenantes ont souligné le manque de recommandations sur la façon d’aborder le sujet des pratiques sexuelles à risques en consultation et sur le repérage des souffrances psychologiques chez les personnes vulnérables (contexte de violence, de rupture avec le milieu de naissance dans un contexte migratoire). Les éléments réunis dans cette synthèse sont donc très incomplets, et la méthodologie employée dans le cadre de la présente évaluation ne permettait pas de formuler de nouvelles recommandations, en particulier sur des sujets aussi complexes. En effet, les professionnels de santé impliqués avaient été sollicités au titre de parties prenantes et nom au titre d’experts, comme la HAS peut être amenée le faire dans le cadre de groupes de travail ou de groupes de lecture .Les principales informations ont été discutées avec l’ensemble des parties prenantes le 5 juin 2015, à la HAS et au sein d’un groupe plus restreint, réunissant uniquement les professionnels de santé participant au groupe de parties prenantes le 3 juillet 2015. L’objectif de cette seconde réunion était de vérifier l’exactitude scientifique des éléments rapportés dans le cadre de cette synthèse. Lorsque des précisions étaient apportées par les professionnels de santé impliqués, il est précisément explicité qu’il s’agit de propositions émanant des membres de ce groupe de parties prenantes .La revue de la littérature sur les recommandations existantes a été effectuée jusqu’au mois d’août 2015. Le présent document ne prend donc pas en compte les recommandations qui seraient publiées après cette date. Il est possible que la compréhension du contenu de ce document puisse être freinée par l’usage de termes techniques, plus ou moins familiers aux acteurs, en fonction de leurs connaissances médicales. Le cas échéant, un travail de simplification des terminologies employées pourrait être effectué par la HAS ou par d’autres institutions. Une méthodologie de travail ad hoc devrait toutefois être définie.   Résumé des recommandations de prévention et de prise en charge des Infections sexuellement transmissibles, troubles gynécologique et urologiques Conclusion de la revue de la littérature Les données disponibles n’indiquent pas que l’activité prostitutionnelle est en soi un facteur de risque d’infection du VIH/Sida, sauf lorsqu’elle est associée à des facteurs de vulnérabilité psychologique, sociale et économique qui favorisent la propension de personnes en situation de prostitution/tds à accepter des rapports non protégés à la demande de certains clients. Les HSH et les personnes transgenres qui se prostituent/tds restent en revanche beaucoup plus exposées que les femmes, comme le sont ces personnes en population générale. Les données sur la prévalence des hépatites B et C chez les personnes en situation de prostitution/tds sont assez rares et elles ne sont pas convergentes si bien qu’il n’est pas possible ne permettent pas de tirer des conclusions robustes. Les études disponibles ne permettent pas de conclure sur l’existence d’un sur-risque vis-à-vis de l’hépatite B et C. L’activité prostitutionnelle est par ailleurs associée à une surexposition à d’autres IST moins connues que le VIH/Sida (chlamydia, gonocoque et papillomavirus) et à certains troubles gynécologiques (vaginose, candidose, inflammation pelvienne).

Henriquet, M., et al. (2021). "Comment la mobilisation des savoirs expérientiels participe à la réduction des inégalités sociales de santé de personnes précaires et stigmatisées : l’exemple de l’accompagnement des travailleur.euse.s du sexe de rues migrant.e.s au sein des associations de santé communautaires"

A partir d’une revue de littérature documentant l’apport des savoirs expérientiels dans le champ de la santé mentale, ce travail s’est intéressé à étudier les freins et leviers de leur mobilisation dans un autre contexte. L’accompagnement des Travailleur.euse.s Du Sexe (TdS) de rue, migrant.e.s, au sein d’associations de santé, qui promeuvent les compétences des personnes concerné.e.s. Différents concepts : la migration, le cadre juridique et le travail sexuel ainsi que leurs articulations ont été explicités. Une analyse des déterminants sociaux de la santé des TdS a démontré que leurs conditions d’exercice et de vie, affectent leur santé mentale. Une méthode d’analyse qualitative a permis, en croisant deux points de vue situés, de documenter les conditions qui favorisent la mobilisation des savoirs expérientiels des travailleur.euse.s pair.e.s. Le but étant d’agir sur les déterminants sociaux des TdS, afin de réduire les inégalités sociales de santé. Des recommandations ont ensuite été proposées. (R.A.)

Jauffret Roustide, M., et al. (2008). "Trajectoires de vie et prises de risques chez les femmes usagères de drogues." Med Sci 24(HS 2): 111-121.

En France, la population des usagers de drogues est majoritairement masculine. Parmi ceux-ci, les profils et les pratiques des femmes sont mal connus. Entre 2004 et 2007, l'enquête Anrs-Coquelicot, alliant épidémiologie et socio-anthropologie, a permis de décrire les profils des usagers des drogues et d'analyser les situations à risque vis-à-vis du VIH et du VHC, en prenant en compte la problématique du genre. Les entretiens montrent que les femmes ont fréquemment connu des événements marquants durant l'enfance et l'adolescence (violences). C'est généralement dans ce contexte qu'elles s'initient aux drogues par le biais de rencontres amoureuses. Elles adoptent globalement plus de comportements à risque que les hommes et ont davantage recours à la prostitution. Ainsi, ces femmes ont des trajectoires encore plus chaotiques que celles des hommes. Elles sont confrontées à une double fragilité vis-à-vis du VIH et du VHC liée au contexte de leur consommation de drogues et de leur sexualité.

Lot, F., et al. (2013). "Étude ProSanté 2010-2011 sur l'état de santé, l'accès aux soins et l'accès aux droits des personnes en situation de prostitution rencontrées dans des structures sociales et médicales." Bull Epidemiol Hebd(39-40): 517-523.

La Fédération nationale des associations d'accueil et de réinsertion sociale (Fnars) et l'Institut de veille sanitaire (InVS) ont conduit une étude en deux volets, dans une démarche de recherche-action, afin d'améliorer les connaissances sur l'état de santé, l'accès aux soins et aux droits des personnes en situation de prostitution. Au total, 251 personnes ont participé au volet santé-social de l'étude, réalisé au sein de structures sociales, et 78 personnes ont participé au volet médical, réalisé dans des Centres d'information, de dépistage et de diagnostic des infections sexuellement transmissibles (Ciddist) ou des Centres de planification ou d'éducation familiale (CPEF). Les deux tiers des personnes enquêtées étaient des femmes et les trois-quarts (78%) étaient de nationalité étrangère. Elles cumulaient de nombreux indicateurs de précarité (environnement social, conditions de logement, titre de séjour, couverture maladie). Plus de la moitié des répondants ont déclaré être dans un état de santé moyen, mauvais ou très mauvais, proportion bien supérieure à la population générale. Les femmes présentaient une vulnérabilité particulière sur le plan gynéco-obstétrical (faible prévention vis-à-vis du cancer du col de l'utérus, faible utilisation d'une contraception orale et fort recours aux interruptions volontaires de grossesse). Les personnes transgenres étaient largement touchées par le VIH, avec une prévalence déclarée de 44%. La population de l'étude, fragile sur le plan de la santé psychique, était particulièrement exposée aux violences physiques et psychologiques. Compte tenu des structures sollicitées, cette étude n'est pas représentative de l'ensemble de la population des personnes en situation de prostitution en France. Elle permet néanmoins de formuler des recommandations en termes de prévention et d'accès aux droits et aux soins. (R.A.)

Lot, F. et Therre, H. (2013). "Etude ProSanté 2010-2011. Etude sur l'état de santé, l'accès aux soins et l'accès aux droits des personnes en situation de prostitution rencontrées dans des structures sociales et médicales". Saint-Maurice Paris, Institut de veille sanitaire Fédération Nationale des Associations d'accueil et de Réinsertion Sociale (FNARS).

La Fédération nationale des associations d'accueil et de réinsertion sociale (FNARS) et l'Institut de veille sanitaire (InVS) ont conduit une étude sur la santé des personnes en situation de prostitution, dans une démarche de recherche-action, dans le but de contribuer à l'amélioration de la prise en charge médico-sociale de cette population. Au total, 251 personnes ont participé au volet Santé-social de l'étude, réalisé au sein de structures associatives et 78 personnes ont participé au volet médical, réalisé dans des Centres d'information, de dépistage et de diagnostic des infections sexuellement transmissibles (Ciddist) ou des Centres de planification ou d'éducation familiale (CPEF). Plus des trois-quarts (78 %) des personnes enquêtées étaient de nationalité étrangère et les deux tiers étaient des femmes. Les personnes enquêtées cumulaient de nombreux facteurs de précarité sociale (isolement relationnel, conditions de logement, titre de séjour, couverture maladie). Plus de la moitié des personnes ont déclaré être dans un état de santé moyen, mauvais ou très mauvais, proportion bien supérieure à la population générale. Les femmes présentaient une vulnérabilité particulière sur le plan gynéco-obstétrical (faible prévention vis-à-vis du cancer du col de l'utérus, faible utilisation d'une contraception orale et fort recours aux IVG). Les personnes transgenres étaient largement touchées par le VIH, avec une prévalence déclarée de 44 %. La population de l'étude, fragile sur le plan de la santé psychique, était particulièrement exposée aux violences physiques et psychologiques. Compte tenu des structures sollicitées, cette étude n'est pas représentative de l'ensemble de la population des personnes en situation de prostitution en France. Elle permet néanmoins de formuler des recommandations en termes de prévention et d'accès aux droits et aux soins.

Protesta, A. (2024). "Santé mentale des travailleurs et travailleuses du sexe: la «rationalité» scientifique au détriment des droits." Journal du Droit de la Santé et de l’Assurance-Maladie (JDSAM) 40(2): 46-48.

Prescrire, R. (2020). "La santé des personnes travailleuses du sexe en danger." Revue Prescrire(40): 463-464.

Rubio, V. (2019). "Sexualité, marchandisation et risque VIH. Le cas des clients de la prostitution masculine sur internet déclarant des rapports sexuels sans préservatif." Sciences sociales et sante Vol. 37(3): 71-96.

https://stm.cairn.info/revue-sciences-sociales-et-sante-2019-3-page-71

Résumé Cet article s’intéresse à l’occurrence de rapports sexuels sans préservatif dans le contexte de la prostitution entre hommes sur internet. Il en rend compte à partir de l’expérience de clients en s’appuyant sur une enquête de deux ans menée en France auprès de 34 hommes recourant aux services d’escorts. La non-utilisation du préservatif y apparaît étroitement liée à l’interprétation que ces hommes font du cadre relationnel dans lequel ils estiment se trouver engagés avec leur(s) partenaire(s) tarifé(s). En l’occurrence, les transactions prostitutionnelles se révèlent irréductibles au seul échange d’argent et de services sexuels. En mettant en évidence la connaissance faible qu’ont ces hommes des dernières avancées de la prévention en matière de VIH (la Prophylaxie Pré-exposition notamment), l’article souligne par ailleurs un des angles morts de la perspective de la fin de l’épidémie.

A l’étranger

Bar-Johnson, M. et Weiss, P. (2014). "Mental health and sexual identity in a sample of male sex workers in the Czech Republic." Med Sci Monit 20: 1682-1686.

BACKGROUND: Previous qualitative research has examined male sex workers in the Czech Republic, but this mapping study is the first to investigate male sex work in a quantitative research design and focus on the mental health of these sex workers. This study also examines male sex workers' mental health problems in relation to their sexual identity or orientation. MATERIAL AND METHODS: A sample of Czech male sex workers (N=40) were examined on a range of sexual and psychological variables using a quantitative survey administered face-to-face. The study employed locally validated versions of Beck's Depression Inventory and Zung's Self-Report Anxiety Scale. RESULTS: The results indicate that for homosexuals, working as a male sex worker is not related to any serious mental health problems. However, those identifying as heterosexual and bisexual more frequently reported symptoms of depression and bisexuals showed significantly more anxiety. CONCLUSIONS: These findings suggest sexual identity is an important issue to consider when addressing the mental health needs of this population.

Belza, M. J. (2004). "Prevalence of HIV, HTLV-I and HTLV-II among female sex workers in Spain, 2000-2001." Eur J Epidemiol 19(3): 279-282.

Using an unlinked anonymous survey the seroprevalence of HIV, HTLV-I and HTLV-II was analysed among female sex workers. They were surveyed when they attended sexually transmitted disease clinics in six Spanish cities during the period 2000-2001. Fifty-eight percent of the 3149 women analysed came from Latin America or sub-Saharan Africa. The total prevalence of HIV was 0.7%, rising to 15.9% amongst injecting drug users (IDUs). When this group was not included, the prevalence amongst the Latin-Americans or sub-Saharan Africans was 0.8% and amongst the women from other origins 0.3% (p = 0.148). 33.3% of the women infected with HIV already knew about their infection. The prevalences of HTLV-I and HTLV-II were 0.3% and 0.2%, respectively. The prevalences of these three infections in this collective were low if evaluated without the IDUs.

Benoit, C., et al. (2018). "Prostitution Stigma and Its Effect on the Working Conditions, Personal Lives, and Health of Sex Workers." J Sex Res 55(4-5): 457-471.

Researchers have shown that stigma is a fundamental determinant of behavior, well-being, and health for many marginalized groups, but sex workers are notably absent from their analyses. This article aims to fill the empirical research gap on sex workers by reviewing the mounting evidence of stigmatization attached to sex workers' occupation, often referred to as "prostitution" or "whore" stigma. We give special attention to its negative effect on the working conditions, personal lives, and health of sex workers. The article first draws attention to the problem of terminology related to the subject area and makes the case for consideration of prostitution stigmatization as a fundamental cause of social inequality. We then examined the sources of prostitution stigma at macro, meso, and micro levels. The third section focuses on tactics sex workers employ to manage, reframe, or resist occupational stigma. We conclude with a call for more comparative studies of stigma related to sex work to contribute to the general stigma literature, as well as social policy and law reform.

Bianchi, F. T., et al. (2013). "Sex with sex workers among latino day laborers in Suburban Maryland." Arch Sex Behav 42(5): 835-849.

Using the structural-environmental conceptual framework, this study employed mixed methods to address the question of whether sex with female sex workers contributes to HIV risk among male immigrant Latino day laborers in suburban Maryland. Because contextual factors can greatly affect HIV risk for both sex workers and their clients, this study investigated the organizational structure of sex work, factors that predicted men's hiring of sex workers, sexual behaviors performed with sex workers, and the use of condoms. Qualitative research was conducted to inform the development of a quantitative survey, but also provided crucial descriptions about the motivations, locations, arrangements, and sexual activities related to sex work. Key informant interviews (N = 10), in-depth interviews with day laborers (N = 10) and Latina female sex workers (N = 4), and two focus groups with day laborers (N = 11) were conducted, and a quantitative survey administered via Audio-enhanced Computer-assisted Self-interviewing (N = 174). Condom use was nearly universal in encounters with female sex workers, thus indicating that the sex workers were not an important source of HIV transmission in this context. Logistic regression was performed to test a model predicting sex with sex workers. Latino day laborers who reported more immigrant stress and who did not have a partner in the U.S. were more likely to have had sex with a sex worker, as were men who reported binge drinking. Structural and social conditions influenced the hiring of sex workers. Further research is warranted to better understand the interrelationships among these circumstances and to inform the development of programs to address them.

Boucher, V. G., et al. (2023). "Canadian healthcare workers' mental health and health behaviours during the COVID-19 pandemic: results from nine representative samples between April 2020 and February 2022." Canadian Journal Of Public Health-Revue Canadienne de Santé Publique 114(5): 823-839.

Objective In the context of COVID-19, Canadian healthcare workers (HCWs) worked long hours, both to respond to the pandemic and to compensate for colleagues who were not able to work due to infection and burnout. This may have had detrimental effects on HCWs' mental health, as well as engagement in health-promoting behaviours. This study aimed to identify changes in mental health outcomes and health behaviours experienced by Canadian HCWs throughout the COVID-19 pandemic. Methods Nine representative samples (N-total = 1615 HCWs) completed the iCARE survey using an online polling firm between April 2020 (Time 1) and February 2022 (Time 9). Participants were asked about the psychological effects of COVID-19 (e.g., feeling anxious) and about changes in their health behaviours (e.g., alcohol use, physical activity). Results A majority of the HCWs identified as female (65%), were younger than 44 years old (66%), and had a university degree (55%). Female HCWs were more likely than male HCWs to report feeling anxious (OR = 2.68 [1.75, 4.12]), depressed (OR = 1.63 [1.02, 2.59]), and irritable (OR = 1.61 [1.08, 2.40]) throughout the first two years of the pandemic. Female HCWs were more likely than their male counterparts to report eating more unhealthy diets (OR = 1.54 [1.02, 2.31]). Significant differences were also revealed by age, education level, income, parental status, health status, and over time. Conclusion Results demonstrate that the impacts of COVID-19 on HCWs' mental health and health behaviours were significant, and varied by sociodemographic characteristics (e.g., sex, age, income).

Bradbury-Jones, C., et al. (2017). "Psychiatric morbidity among female commercial sex workers." BMJ Open 59(4): 465-470.

CONTEXT: Psychological distress is higher in women working in sex industry. The various psycho social issues are associated with female commercial sex workers (FCSWs). The host of psychosocial vulnerabilities including, childhood sexual abuse, exposure to childhood physical abuse, poverty, interpersonal violence in adulthood, sexually transmitted diseases, and substance use, forms a fertile ground for psychiatric morbidity. AIM: This study aims to assess the psychiatric morbidity among FCSWs in Shillong, India. MATERIALS AND METHODS: In the present study, 100 FCSWs were selected. For the recruitment of sample, simple random sampling procedure was followed; sociodemographic data sheet and the Mini International Neuropsychiatric Interview were administered. RESULTS: In the study, it was found that 9% of the respondents reported having major depressive episode (current), 25% of the respondents reported major depressive episode (past), 3% were having major depressive episode with melancholic features (current), 21% of the respondents reported posttraumatic stress disorder (PTSD), 8% of the respondents reported to have alcohol dependence, 3% of the respondents reported to have nonalcohol psychoactive substance use disorder, 8% of the respondents were found to have generalized anxiety disorder, and 9% of the respondents were found to have antisocial personality disorder. CONCLUSIONS: There is a prevalence of mental health problems in the FCSW. Assessment of the psychiatric morbidity in FCSW is significant in developing health policy and interventions to reduce their impact on their well-being. It is the immediate need that the governmental and nongovernmental agencies, mental health professionals, and workers in this area need to be sensitized to the issue of mental health status of the commercial sex workers.

Brunswig, F., et al. (2025). "Sex Work Stigma and Psychological Distress-A Mixed-Methods Analysis of an International Sample of Sex Workers." Sexuality Research and Social Policy.

https://link.springer.com/article/10.1007/s13178-025-01133-4

Introduction Research shows that sex workers are particularly vulnerable to mental health challenges. As sex workers are a very heterogeneous group, research focusing on associations between personal working conditions of sex workers and their mental health is needed. Methods In this cross-sectional, anonymous online survey, we used Spearman rank order correlations to examine, in a convenience sample of 76 sex workers from different countries surveyed in 2022, whether the degree of self-determination in the engagement in sex work, the degree of self-organization of sex work, the role-identification as a sex worker, and sex work motive (engaging in sex work to meet financial needs versus for pleasure) and internalized sex work stigma (Internalized Sex work Stigma Scale) are associated with psychological distress (Patient-Health-Questionnaire-4). Thematic analysis of open text answers was used to identify sex workers' suggestions for political and social change. Results Psychological distress was negatively correlated with self-determination and positively correlated with internalized sex work stigma. The participants advocated for the decriminalization and destigmatization of sex work, improved access to health care, improved workers' rights, and fighting sexual exploitation. Conclusions The results emphasize the need for efforts to challenge stigmatization of sex workers, internalized stigma in sex workers, and the need to counteract working conditions where sex workers' self-determination is limited. Destigmatization, decriminalization, health care access, workers' rights, and sexual exploitation are topics of concern to sex workers. Policy Implications. Perspectives by sex workers should be used to inform policy decisions to first understand and then better implement the needs of this diverse group. Conclusions The results emphasize the need for efforts to challenge stigmatization of sex workers, internalized stigma in sex workers, and the need to counteract working conditions where sex workers' self-determination is limited. Destigmatization, decriminalization, health care access, workers' rights, and sexual exploitation are topics of concern to sex workers. Policy Implications. Perspectives by sex workers should be used to inform policy decisions to first understand and then better implement the needs of this diverse group. Conclusions The results emphasize the need for efforts to challenge stigmatization of sex workers, internalized stigma in sex workers, and the need to counteract working conditions where sex workers' self-determination is limited. Destigmatization, decriminalization, health care access, workers' rights, and sexual exploitation are topics of concern to sex workers. Policy Implications. Perspectives by sex workers should be used to inform policy decisions to first understand and then better implement the needs of this diverse group.

Chow, E. P., et al. (2014). "Testing commercial sex workers for sexually transmitted infections in Victoria, Australia: an evaluation of the impact of reducing the frequency of testing." PLoS One 9(7): e103081.

BACKGROUND: The frequency of testing sex workers for sexually transmitted infections (STIs) in Victoria, Australia, was changed from monthly to quarterly on 6 October 2012. Our aim was to determine the impact of this change to the clients seen at the Melbourne Sexual Health Centre (MHSC). METHODS: Computerised medical records of all clients attending at MHSC from 7 October 2011 to 7 October 2013 were analysed. RESULTS: Comparing between the monthly and quarterly testing periods, the number of consultations at MSHC with female sex workers (FSW) halved from 6146 to 3453 (p<0.001) and the consultation time spent on FSW reduced by 40.6% (1942 h to 1153 h). More heterosexual men (p<0.001), and women (p<0.001) were seen in the quarterly testing period. The number of STIs diagnosed in the clinic increased from 2243 to 2589 from the monthly to quarterly period, respectively [15.4% increase (p<0.001)]. Up to AU$247,000 was saved on FSW testing after the shift to quarterly testing. CONCLUSIONS: The change to STIs screening frequency for sex workers from monthly to quarterly resulted in a 15% increase in STI diagnoses in the clinic and approximate a quarter of a million dollars was diverted from FSW testing to other clients. Overall the change in frequency is likely to have had a beneficial effect on STI control in Victoria.

Chow, E. P., et al. (2019). "Prevalence of genital and oropharyngeal chlamydia and gonorrhoea among female sex workers in Melbourne, Australia, 2015-2017: need for oropharyngeal testing." Sex Transm Infect 95(6): 398-401.

OBJECTIVE: The Victorian legislation requires sex workers to have quarterly screening for genital chlamydia and gonorrhoea, but screening for oropharyngeal infection is not mandatory in Victoria, Australia. In 2017, oropharyngeal screening for gonorrhoea and chlamydia was added as part of the routine quarterly screening for sex workers attending the Melbourne Sexual Health Centre (MSHC). The aim of this study was to examine the prevalence of oropharyngeal gonorrhoea and chlamydia among female sex workers (FSW). METHODS: We included females who (1) self-identified as sex workers or were attended MSHC for a sex work certificate and (2) had tested for any STI or HIV, between March 2015 and December 2017. The prevalence of HIV, syphilis, chlamydia and gonorrhoea was calculated. RESULTS: There were 8538 FSW consultations among 2780 individuals during the study period. There was a twofold increase in genital gonorrhoea (from 0.5% (95% CI 0.3% to 0.9%) to 1.1% (95% CI 0.8% to 1.5%); p(trend)=0.047) and a 1.5-fold increase in genital chlamydia (from 2.2% (95% CI 1.6% to 2.8%) to 3.2% (95% CI 2.6% to 3.8%); p(trend)=0.031) during the period. Overall, the prevalence of HIV (0.2% (95% CI 0.1% to 0.3%)) and syphilis (0.1% (95% CI 0.0% to 0.2%)) remained low and did not change over time. In 2017, the prevalence of oropharyngeal gonorrhoea was 2.0% (95% CI 1.6% to 2.6%) and oropharyngeal chlamydia was 2.1% (95% CI 1.6% to 2.7%). Among FSW who were tested positive for gonorrhoea and chlamydia, 55% (n=41) and 34% (n=45) only tested positive in the oropharynx but not genital for gonorrhoea and chlamydia, respectively. CONCLUSION: The prevalence of oropharyngeal gonorrhoea and chlamydia is similar to the prevalence at genital sites and is often independent of genital infection. It is important to test the oropharynx and genital site for chlamydia and gonorrhoea among FSW.

Dias, S., et al. (2015). "Risk-taking behaviours and HIV infection among sex workers in Portugal: results from a cross-sectional survey." Sex Transm Infect 91(5): 346-352.

OBJECTIVES: Sex workers (SW) are key populations at an increased risk of HIV infection. This study aimed to characterise risk-taking behaviours and assess HIV prevalence among SW in Portugal. METHODS: A cross-sectional survey was conducted with 1040 SW using a participatory research approach. SW were recruited in sex-work locations and community-based organisation offices. Data were collected through a questionnaire with trained interviewers. An HIV rapid test was performed in 213 respondents. RESULTS: Reported HIV prevalence was 8%: 17.6% of man-to-woman transgenders, 7.4% of women and 5% of men. Of SW reportedly living with HIV, 52.2% reported ever injecting drug use. Inconsistent condom use with clients in the last month was higher among male SW (26.5%) and with non-paying partners in the last year was higher among women (71.3%). Among reported HIV-positive SW, the proportions of inconsistent condom use were high. In multivariate regression analysis, reported HIV infection remained significantly higher among transgenders (OR 6.4; 95% CI 1.7 to 24.3), those older (OR 5.1; 95% CI 1.3 to 21.1), working outdoors (OR 5.4; 95% CI 1.9 to 15.6), having ever used psychoactive substances (OR 4.1; 95% CI 2.2 to 7.7) and earning ≤€1000 per month (OR 2.6; 95% CI 1.2 to 5.9). Of those who had an HIV rapid test, 8.9% were reactive; 73.7% were unaware of their seropositivity. CONCLUSIONS: The HIV infection burden in SW is high. Efforts to promote HIV testing must be sustained in order to reduce undiagnosed infection. The diverse risk profiles of SW must be addressed in targeted HIV interventions. Prevention interventions should be systematically implemented within most-at-risk subgroups of SW.

Dias, S., et al. (2017). "Health Services Use and HIV Prevalence Among Migrant and National Female Sex Workers in Portugal: Are We Providing the Services Needed?" AIDS Behav 21(8): 2316-2321.

This cross-sectional bio-behavioral survey conducted with 853 female sex workers (FSW) aimed to examine differences in use of HIV health services, testing and prevalence among migrant and national FSW. A quarter of undocumented FSW had never used National Health Service (NHS) and 15 % never tested for HIV, significantly more than nationals (p < 0.001 and p = 0.024, respectively). HIV infection was self-reported by 11.9 % of nationals, 1.8 % of documented and 0.8 % of undocumented migrants (p < 0.001). The HIV rapid test was reactive in 13.6 % of undocumented, 8.0 % of nationals and 2.3 % of documented. A higher proportion of migrants were unaware of their positive serostatus compared to nationals. Ever had HIV testing was less likely among undocumented, who never used the NHS and who didn't know where to go if suspected being HIV-infected. Promoting early diagnosis with linkage to care among migrant FSW should be supported, while developing health services better tailored to their needs.

European Centre for Disease Prevention and Control. (2024). "HIV and sex workers Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia: 2022 progress report."  Solna : ECDC

https://www.ecdc.europa.eu/sites/default/files/documents/HIV-and-sex-workers-2022.pdf

This report presents the available data for describing the current situation regarding HIV prevalence among sex workers, and the efforts being made across Europe and Central Asia towards HIV prevention among this population.

Flaherty-Gupta, A., et al. (2025). "418 Factors associated with HIV amongst migrant MSM in Europe." European Journal of Public Health 35(Supplement_6).

https://doi.org/10.1093/eurpub/ckaf180.332

EP1.4, e-Poster Terminal 1, September 4, 2025, 11:35 - 13:00 Aims In 2022 migrants comprised 48% of all new HIV diagnoses in the EU/EEA and only four countries provided data across the care continuum for migrants. We sought to implement a HIV screening strategy for migrants in 10 European countries. Methods Between April 2022 – March 2023, we conducted the Mi-Health HIV Partnership, a study of migrants in 10 European countries (Belgium, Cyprus, England, France, Germany, Greece, Italy, Netherlands, Portugal, Sweden). HIV infection was determined by combined antibody/antigen, point-of-care, rapid blood or rapid oral test. Additional study variables were collected through a survey of all participants. Results We screened 2402 migrants and diagnosed 154 with HIV, a prevalence rate of 6.41%. Amongst the subset of migrants self-identifying as MSM (n = 413), 74 were diagnosed with HIV, a prevalence rate of 17.92%. Of the HIV-positive MSM, 64.86% identified as South/Central American, compared to 47.46% of all MSM sampled. Higher levels (90.54%) of HIV-positive MSM were linked into healthcare compared to all MSM (48.43%). Additionally, 10.82% of HIV-positive MSM reported no/limited access to healthcare as compared to 19.73% of all MSM with no/limited access. Substantially higher levels of HIV-positive MSM (47.30%) reported stigma/racism/discrimination as their primary barrier to healthcare access as compared to all MSM in our sample (34.14%). Markedly higher levels of HIV-positive MSM identified engaging in sex work or sex with a sex worker as their primary behavioural vulnerability as compared to all MSM (64.86% versus 35.59%, respectfully). Finally, HIV-positive MSM reported lower levels of both PrEP awareness (43.24%) and using PrEP at least once in the previous year (4.05%) as compared to all MSM (68.28% and 13.08%, respectfully). Conclusions HIV infection rates are higher amongst key population migrants. There is a need to implement community-led, targeted, culturally-sensitive screening, engagement and treatment strategies to address the multilevel barriers faced by migrants.

Glick, J. L., et al. (2020). "Structural vulnerabilities and HIV risk among sexual minority female sex workers (SM-FSW) by identity and behavior in Baltimore, MD." Harm Reduct J 17(1): 43.

BACKGROUND: Research suggests sexual minority female sex workers (SM-FSW) face elevated structural vulnerability and HIV risk compared to their heterosexual counterparts. Structural vulnerabilities reflect societal level factors (e.g., sexism, homophobia, racism) that constrain an individual's agency, particularly related to health outcomes. This study examines the association between SM status by identity and behavior, structural vulnerability, and HIV risk among a sample of street-based FSW. METHODS: The current study utilizes baseline data from the SAPPHIRE study, a prospective cohort of cis gender and transgender FSW in Baltimore, MD, recruited through targeted time-location sampling from April 2016 to January 2017. The current analysis focuses on cisgender women. The baseline survey ascertained demographics, substance use, intimate partner violence (IPV), and sex work characteristics. Multivariable models were constructed using self-identity and behaviorally defined SM status as independent variables with vulnerability outcomes (e.g., injection drug use, injection speedball, binge drinking, homelessness, physical IPV, ever had a pimp, and being a minor at sex work entry (age < 18)) as dependent variables. RESULTS: Of the participants (n = 247), 25.5% (n = 63) self-identified as a SM by identity (e.g., gay or bisexual), and 8.5% (n = 21) reported SM behavior (e.g., same-gender sexual behavior) in the past 3 months. In multivariable logistic regression models, SM status by identity was associated with increased odds of injection drug use, binge drinking, homelessness, physical IPV, and being a minor at sex work entry. SM status by behavior was associated with increased odds of binge drinking, homelessness, ever having a pimp, and being a minor at sex work entry. CONCLUSION: The study indicates disproportionate structural vulnerability and heightened HIV risk among SM-FSW, as compared to their heterosexual counterparts, with differences in their profile by sexual identity and behavior. Findings suggest a need for nuanced interventions tailored to these populations.

Jeal, N., et al. (2008). "The multiplicity and interdependency of factors influencing the health of street-based sex workers: a qualitative study." Sex Transm Infect 84(5): 381-385.

OBJECTIVES: To obtain a detailed understanding of the lives of street-based commercial sex workers (SSWs) and how factors in their lives interrelate to affect their health. METHODS: In-depth interviews with 22 SSW working in Bristol, England. RESULTS: The SSWs described their working day as a continuous cycle of selling sex, buying and using drugs, then returning to work. They explained that they placed themselves at risk of sexually transmitted infections, rape, physical assault, verbal abuse and murder when selling sex and physical violence when buying drugs. Most of the women injected drugs and detailed how this behaviour had resulted in life-threatening illnesses, including deep vein thromboses, pulmonary emboli and abscesses. Some interviewees gave accounts of sleeping in crack houses, on friends' floors or car parks, and most participants mentioned that they did not eat, drink or sleep regularly. This self-neglect led to weight loss and physical and mental ill-health. Respondents described pressures that forced them back out to work, such as unstable accommodation, separation from children and other individuals taking their drugs or money. CONCLUSIONS: SSWs are trapped in a cycle of selling sex and buying and using drugs. Multiple pressures from within and outwith this cycle keep them in this situation. The multiplicity and interdependency of health problems and pressures suggest that this group are best supported with integrated multi-agency services that work flexibly across all areas of their lives. A rigid or punitive approach is likely to be counterproductive and may increase risks to the wellbeing of SSWs.

Jeal, N. et Salisbury, C. (2004). "A health needs assessment of street-based prostitutes: cross-sectional survey." J Public Health (Oxf) 26(2): 147-151.

BACKGROUND: Research with prostitutes has tended to concentrate on sexual health rather than wider health issues, and has failed to differentiate between street-based prostitutes and off-street workers. Little is known about the general health and background of street-based sex workers, the group likely to have the greatest needs. METHODS: An interview-based survey amongst street-based sex workers in central Bristol was employed. RESULTS: Seventy-one women were interviewed. All reported chronic health problems. Sexually transmitted infections were between nine and 60 times more common than the general population. Many women (44 per cent; n = 31) had experienced sexual abuse and 38 per cent (n = 27) had been in care. Women who had experienced care left school earlier (14.1 versus 15.5 years; p < 0.0001 unpaired t-test) and were less likely to have their own children at home [1/18 (5.5 per cent) versus 8/25 (32 per cent); p = 0.06) The stillbirth rate was 50/1000. Most (97 per cent; n = 69) had been offered more money for unprotected sex. Half (51 per cent; n = 36) had unprotected sex in the last week. All had drug or alcohol dependency problems. In the last week, 22 per cent (n = 9/41) of injecting drug users had shared needles and 59 per cent (n = 24/41) had shared injecting equipment, despite most (96 per cent; n = 39/41) knowing the risks. CONCLUSIONS: The health and social inequalities experienced by this group are much worse than any group highlighted in the 'Tackling Health Inequalities Review 2002' and appear cross generational. In neither that report nor the Sexual Health and HIV Strategy report are sex workers identified as a particularly high priority group. There is the potential for their needs to continue to be unmet.

Kalinowski, O., et al. (2025). "Quality of life, mental health, and socio-demographic differences across sex work settings: implications for specialized healthcare and support services." Front Public Health 13: 1703735.

BACKGROUND: Existing research shows that quality of life (QoL), mental health, and working conditions vary widely across sex work settings. Street-based work, for example, involves different risks than, for example, online sex work. Little is known about what drives individuals into specific environments. This study examines whether work setting predicts working conditions, QoL, mental health, and reported socio-medical needs, and explores factors predicting the work setting. The aim is to inform recommendations for more tailored healthcare and support services. METHODS: Data come from PSYCHSEX, a cross-sectional study conducted at the Department of Psychiatry and Neurosciences, Charité University Hospital Berlin (August 2021-August 2024), funded by the German Research Association (DFG). Structured quantitative interviews were conducted with 403 sex workers recruited through quota sampling to represent diverse settings, including private apartments, studios, brothels, massage parlors, clubs, clients' homes, vehicles, guesthouses/hotels, outdoor locations, and online platforms. RESULTS: Work setting was significantly associated with QoL, mental health, and working conditions. Specific settings (e.g., studios, escort work, and online platforms) were linked to better QoL, mental health, and working conditions than others. Socio-demographic factors like migration status and homelessness, along with distinct self-reported reasons for entering sex work, such as personal preference, lack of alternatives, or funding one's education, predicted work setting. Reported socio-medical needs differed across settings. DISCUSSION: Sex work is shaped by diverse settings, conditions, and individual pathways. Variation in QoL, mental health, working conditions, and unmet support needs underscores the need for setting-specific healthcare and social services. Structural factors such as housing instability and migration status play a key role and should be addressed through targeted policies and interventions. These findings highlight the importance of context-sensitive, evidence-based support to improve the wellbeing of sex workers across different environments.

Kesten, J. M., et al. (2007). "Health needs and service use of parlour-based prostitutes compared with street-based prostitutes: a cross-sectional survey." BMJ Open 114(7): 875-881.

OBJECTIVES: To compare the health needs of prostitutes (sex workers) working in massage parlours with that of those working on the streets. DESIGN: Cross-sectional survey. SETTING: Inner city, UK. POPULATION: Women aged 16 years and older selling sex in massage parlours. METHODS: Interviewer-administered questionnaires were undertaken with 71 parlour workers, and results were compared with our previous findings for street sex workers. MAIN OUTCOME MEASURES: Self-reported experiences of health and service use. RESULTS: In comparison with street sex workers, parlour sex workers were less likely to report chronic (43/71 versus 71/71; P < 0.001) and acute (10/71 versus 35/71; P < 0.001) illnesses but more likely to be registered with a GP (67/71 versus 59/71; P = 0.06). They were more likely than street sex workers to have been screened for sexually transmitted infections in the previous year (49/71 versus 33/71; P = 0.011) and more likely to use contraception in addition to condoms (34/71 versus 8/71; P < 0.001). They were less likely to be overdue for cervical screening (5/46 versus 19/48; P = 0.001), and more of those booked for antenatal care in the first trimester attended all follow-up appointments (28/37 versus 14/47; P < 0.001). Fewer parlour sex workers used heroin (4/71 versus 60/71; P < 0.001), crack cocaine (5/71 versus 62/71; P < 0.001) or injected drugs (2/71 versus 41/71 versus; P < 0.001) They reported fewer episodes of intercourse per week (mean 14 versus 22; P < 0.001) with fewer different men (mean 11 versus 19; P < 0.001), less of whom were new (mean 8 versus 13; P < 0.001). CONCLUSIONS: The two groups had very different health experiences, risk-taking behaviour and use of services. To be effective in improving health, different types of service delivered in different settings for different groups are required.

Kramer, S., et al. (2017). "[Data on the sexual health of providers and clients of sexual services for men who have sex with men in Germany]." Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 60(9): 958-970.

Little is known about the sexual health of male providers and clients of transactional sex. The data of participants of the European MSM Internet Survey (EMIS-DE; N = 50,086) who live in Germany were analysed. The outcomes were testing for and diagnoses of HIV and other sexually transmitted infections (STIs), partner numbers, illicit drug use, and sexual happiness in two populations: (1) men who offered and (2) men who paid for transactional sex in the past 12 months.In the age group of under 30 years (n = 19,138), providers of sexual services (escorts) were compared with non-providers; in the age group of 30 years and above (n = 30,948), we compared men who paid for sexual services with those who did not. We applied univariable and multinomial, multivariable logistic regression analyses in both age groups.Of those under the age of 30, 8% (n = 1529) had been paid for sex in the last 12 months, of which 49% were only paid once or twice. Escorts had lower educational achievements, lived more commonly in large cities, were more often born abroad, self-defined less frequently as gay, and were more frequently single. They reported higher numbers of sex partners, more drug use, and more sexual happiness. Escorts were more frequently tested for HIV and STIs, and among the tested, more diagnoses of HIV and STIs were reported, but those with HIV were less likely to be treated. Among those over 30 years, 11% (n = 3334) had paid for sex, the majority (58%) only once or twice. Payers were older, lived more commonly in large cities, and were more likely to be single, bisexual, or living with a woman. Clients used more illicit drugs, sexual enhancement drugs, and sedatives, but reported less sexual happiness. They were less likely to be tested for HIV and STIs.

Mc Grath-Lone, L., et al. (2014). "The sexual health of female sex workers compared with other women in England: analysis of cross-sectional data from genitourinary medicine clinics." Sex Transm Infect 90(4): 344-350.

BACKGROUND: While female sex workers (FSWs) are assumed to be at increased risk of sexually transmitted infections (STIs), there are limited comparative data with other population groups available. Using routine STI surveillance data, we investigated differences in sexual health between FSWs and other female attendees at genitourinary medicine (GUM) clinics in England. METHODS: Demographic characteristics, STI prevalence and service usage among FSWs and other attendees in 2011 were compared using logistic regression. RESULTS: In 2011, 2704 FSWs made 8411 recorded visits to 131/208 GUM clinics, (primarily large, FSW-specialist centres in London). FSWs used a variety of services, however, 10% did not have an STI/HIV test at presentation. By comparison with other female attendees, FSWs travelled further for their care and had increased risk of certain STIs (e.g., gonorrhoea ORadj: 2.76, 95% CI 2.16 to 3.54, p<0.001). Migrant FSWs had better sexual health outcomes than UK-born FSWs (e.g., period prevalence of chlamydia among those tested: 8.5% vs 13.5%, p<0.001) but were more likely to experience non-STI outcomes (eg, pelvic inflammatory disease ORadj: 2.92, 95% CI 1.57 to 5.41, p<0.001). CONCLUSIONS: FSWs in England have access to high-quality care through the GUM clinic network, but there is evidence of geographical inequality in access to these services. A minority do not appear to access STI/HIV testing through clinics, and some STIs are more prevalent among FSWs than other female attendees. Targeted interventions aimed at improving uptake of testing in FSWs should be developed, and need to be culturally sensitive to the needs of this predominantly migrant population.

Mendez-Lopez, A., et al. (2022). "Social and behavioural determinants of syphilis: Modelling based on repeated cross-sectional surveys from 2010 and 2017 among 278,256 men who have sex with men in 31 European countries." Lancet Reg Health Eur 22: 100483.

http://portaildocumentaire.santepubliquefrance.fr/exl-php/vue-consult/spf___internet_recherche/SPF00004088

BACKGROUND: Syphilis case notifications among men-who-have-sex-with-men (MSM) have increased markedly over the past two decades in Europe. We tested several potential factors for this resurgence. METHODS: Self-reported data from two cross-sectional waves of the European MSM Internet Survey (EMIS-2010 and EMIS-2017, N = 278,256 participants living in 31 European countries) were used to fit multivariable hierarchical logistic regression models designed to evaluate potential social, behavioural, and interventional determinants of syphilis diagnosis. Additional multivariable hierarchical negative binomial models investigated determinants of the number of non-steady male condomless anal intercourse (CAI) partners. We tested the hypothesis that more CAI and syphilis-screening are associated with syphilis resurgence, both linked to use of pre-exposure prophylaxis (PrEP). FINDINGS: Between 2010 and 2017, incidence of syphilis diagnosis in the previous 12 months rose from 2.33% (95%CI: 2.26-2.40) of respondents reporting a syphilis diagnosis in 2010 compared with 4.54% (95%CI: 4.42-4.66) in 2017. Major factors contributing to syphilis diagnosis were living with diagnosed HIV (adjusted odds ratio (aOR) 2.67, 95%CI: 2.32-3.07), each additional non-steady male CAI partner (aOR 1.01, 95%CI: 1.01-1.01), recency of STI-screening (previous month vs no screening, aOR 25.76, 95%CI: 18.23-36.41), selling sex (aOR 1.45, 95%CI: 1.27-1.65), and PrEP use (aOR 3.02, 95%CI: 2.30-3.96). Living with diagnosed HIV (adjusted incidence rate ratio (aIRR) 3.91, 95%CI: 3.77-4.05), selling sex (aIRR 4.39, 95%CI: 4.19-4.59), and PrEP use (aIRR 5.82, 95%CI: 5.29-6.41) were associated with a higher number of non-steady male CAI partners. The association between PrEP use and increased chance of syphilis diagnosis was mediated by STI-screening recency and number of non-steady male CAI partners, both substantially higher in 2017 compared to 2010. INTERPRETATION: Syphilis cases are concentrated in three MSM population groups: HIV-diagnosed, PrEP users, and sex workers. Behavioural and interventional changes, particularly more non-steady male CAI partners and recency of STI-screening, are major contributing factors for increasing syphilis diagnoses among MSM in Europe. FUNDING: European Centre for Disease Prevention and Control.

Laurindo da silva, L. (2006). "Les modalités de consommation de drogues chez les prostitués masculins." Sante Publique 18(2): 207-221, tabl.

[BDSP. Notice produite par ENSP EdR0xYCK. Diffusion soumise à autorisation]. Cet article s'intéresse aux modalités de consommation des produits licites et illicites, chez les prostitués masculins, et le sens qu'ils y donnent. Il rend compte d'une recherche menée, par questionnaire, auprès de 252 prostitués (124 travestis et 128 garçons de passe), parmi lesquels 30 (15 de chaque catégorie) ont accordé, en plus un entretien approfondi. D'après les données quantitatives 79% consommaient régulièrement de l'alcool, 75% du tabac et 56% du cannabis. Dans les 30 jours précédant l'enquête, 14% ont déclaré un usage de somnifères, 13% de poppers, 8% de cocaïne et 7% d'ecstasy. Cependant, les entretiens indiquent que tous ne portent pas le même regard sur ces différents produits et que plusieurs logiques de consommation s'en dégagent, ouvrant à des perceptions diversifiées selon le contexte de consommation et leur posture à l'égard de la prostitution.

Móró, L., et al. (2013). "Drug use among sex workers in Hungary." Soc Sci Med 93: 64-69.

Drug use and sex work are both controversial issues with multiple interesting connections. This article presents findings from the first-ever survey on drug use and sex work in Hungary. The study aimed to chart the prevalence, function, and problems of drug use among various groups of sex workers. Survey forms were collected from 510 participants (average age 29.5 years, 91% female) in and near Budapest over a period of six months. The results show that sex workers have manifold higher lifetime prevalence, 84.3%, of illicit drug use compared with the prevalence of the Hungarian general young adult population, 20.9%. In our sample, it was very rare to perform sex work for alcohol or drugs (5%) or for money to purchase alcohol or drugs (20%). Findings also indicate notable relationships between location-based sex work types and the drugs used. One-third of the street sex workers reported regular amphetamine use, but none reported regular cocaine use. On the contrary, no escorts reported regular amphetamine use, but 38% admitted to regular cocaine use. The location of sex work may pose an additional occupational health risk factor for substance use. Regular use of alcohol was twice as typical (64%) for sex workers who were employed in bars, in salons/parlors, or alone in rented apartments than it was for those working in other indoor locations (33-34%). Furthermore, 74% of street sex workers smoked tobacco compared with 17% of escorts. Problem drug use was roughly estimated by asking the participants about the main problem domains (medical, legal, social, etc.) from the Addiction Severity Index instrument. The most problematic drug was amphetamine, and the most frequent problem was prolonged or excessive drug use. These main findings may contribute to more focused planning of health intervention services, harm reduction measures, outreach programs, and specific treatments.

Pandey, A. K. et Seelman, K. (2022). "History of Sex Work Is Associated with Increased Risk of Adverse Mental Health and Substance Use Outcomes in Transgender Adults." Int J Environ Res Public Health 19(23).

Understanding factors influencing mental health and substance use in transgender and gender diverse people is critical to reducing disparities in this population. We sought to investigate whether a history of sex work was associated with increased prevalence of poor mental health, substance use, and a negative experience within drug and alcohol treatment facilities. We conducted a secondary analysis of the data of 25,204 transgender respondents of the 2015 United States Transgender Survey. We estimated multiple logistic regressions to assess the association between a history of sex work and adverse mental health and substance use outcomes. We then estimated mean prevalence of adverse outcomes by type of sex work. Finally, we performed chi-square analysis to explore differences in mistreatment at drug and alcohol treatment facilities. Respondents with a history of sex work were significantly more likely to have poorer psychological health, suicidality, and substance use after adjusting for covariates. Among those who visited drug and alcohol treatment facilities, those with a history of sex work were significantly more likely to report adverse experiences (26.34% vs. 11.63%). Our findings highlight the increased risk of adverse outcomes in transgender sex workers and emphasize the need for interventions targeting this subgroup of transgender people.

Pantoja-Maldonado, D. Z., et al. (2025). "[Health care for women in situation of prostitution: systematized narrative review]." Rev Esp Salud Publica 99.

OBJECTIVE: The context in which women in prostitution find themselves makes them more susceptible to suffering violence of multiple characteristics, including the violation of the right to health of many of them, conditioned by prejudices related to venereal diseases, common administrative irregularity or the inherent stigma. The objective of this work was to identify the main challenges of health care for women in prostitution. METHODS: A systematic narrative review was carried out by searching the Scielo, PubMed, Dialnet and Cuiden databases for primary studies published between 2018 and 2023. The literature search was carried out by peer review between the months of January and March 2023. RESULTS: A total of 19 articles were selected, highlighting the thematic lines: access to the Health System; prevalence and risk factors for HIV and other STIs; HIV prevention and use of PrEP; and comprehensive and biopsychosocial care for the health problems of women in prostitution. CONCLUSIONS: Health care for women in prostitution generally focuses on sexual and reproductive health, but health care should cover their health more broadly, given that they have significant needs in the area of mental health, exposure to violence, and hygiene and health conditions. Self-care practices are essential for women themselves to take an active role in prevention and health promotion.

Park, J. N., et al. (2020). "A fentanyl test strip intervention to reduce overdose risk among female sex workers who use drugs in Baltimore: Results from a pilot study." Addict Behav 110: 106529.

BACKGROUND: In 2018, there were over 67,000 drug overdose deaths in the United States, with almost half involving illicit fentanyl and other synthetic opioids. While overall age-adjusted drug overdose deaths decreased by 4.6% from 2017 to 2018, synthetic opioid deaths increased 10.0%. This pilot study evaluates the impact of a brief fentanyl test strip (FTS) intervention to increase fentanyl awareness and reduce overdose risk. METHODS: Female sex workers (FSW) reporting past month illicit opioid use were recruited between April 2018 through February 2019 in Baltimore City, Maryland. At baseline, they completed a baseline survey, and received tailored harm reduction messaging, 5 FTS and training, and a naloxone kit, then completed a survey after one month. McNemar's test was used to compare repeated measures. RESULTS: Among N = 103, 54% were <40 years, 59% were white, and 24% had overdosed in the past year. Among 68 who completed follow-up, most (84%) used ≥1 FTS to test their drugs, 86% had ≥1 fentanyl-positive result, 57% were surprised by the result, and 69% engaged in harm reduction behaviors following the result (e.g., asked someone to check on them, did a tester shot, used a smaller amount). Significant pretest-posttest reductions in daily illicit opioid use (77% to 56%; p = 0.003), injection frequency (40% to 25%; p = 0.004), benzodiazepine use (22% to 7%; p = 0.008), and solitary drug use (96% vs. 68%; p < 0.001) were observed. No change in preferring drugs containing fentanyl was found. Some (18%) gave their FTS to others. All but three (96%) reported being likely to use FTS in the future. CONCLUSIONS: We found high FTS acceptability and reductions in drug use frequency and solitary drug use following FTS use among FSW who use drugs in Baltimore. These findings demonstrate that FTS-based interventions hold potential in reducing overdose risk.

Park, J. N., et al. (2019). "Incidence and Predictors of Chlamydia, Gonorrhea and Trichomonas Among a Prospective Cohort of Cisgender Female Sex Workers in Baltimore, Maryland." Sex Transm Dis 46(12): 788-794.

BACKGROUND: Cisgender female sex workers (CFSWs) have elevated rates of sexually transmitted infections (STI) yet are underrepresented in targeted programming and research in the United States. We examined the prevalence, incidence and predictors of chlamydia, gonorrhea, and trichomonas infection among CFSW. METHODS: Two hundred fifty street-based CFSWs were recruited into a prospective observational cohort in Baltimore, Maryland using targeted sampling in 2016 to 2017 and completed surveys and STI testing at baseline, 3, 6, 9, and 12 months. Cox proportional hazards regression was used to model the predictors of STI. RESULTS: Mean age was 36 years, and 66.5% of respondents were white. Baseline prevalence of chlamydia, gonorrhea, trichomonas was 10.5%, 12.6%, and 48.5%, respectively. The incidence of chlamydia, gonorrhea, and trichomonas was 14.3, 19.3, 69.1 per 100 person-years. Over one year of observation, past year sex work initiation predicted both chlamydia incidence (adjusted hazard ratio [aHR], 2.7; 95% confidence interval [CI], 1.3-6.0) and gonorrhea incidence (aHR, 1.7; 95% CI, 1.0-2.8). Client sexual violence predicted gonorrhea incidence (aHR, 2.9; 95% CI, 1.2-7.1) and having female sexual partners predicted trichomonas incidence (aHR, 3.4; 95% CI, 1.3-8.5). Having a usual health care provider (aHR, 0.6; 95% CI, 0.5-0.7) was inversely associated with trichomonas. CONCLUSIONS: In this study of urban US street-based CFSW, interpersonal and structural factors differentially predicted STIs, and infection rates remained elevated through follow-up despite regular testing, notification, and treatment referral. Focused and multifaceted interventions for sex workers and their sexual partners are urgently needed.

Paz-Bailey, G., et al. (2016). "Prevalence of HIV Among U.S. Female Sex Workers: Systematic Review and Meta-analysis." AIDS Behav 20(10): 2318-2331.

Although female sex workers are known to be vulnerable to HIV infection, little is known about the epidemiology of HIV infection among this high-risk population in the United States. We systematically identified and critically assessed published studies reporting HIV prevalence among female sex workers in the United States. We searched for and included original English-language articles reporting data on the prevalence of HIV as determined by testing at least 50 females who exchanged sexual practices for money or drugs. We did not apply any restrictions on date of publication. We included 14 studies from 1987 to 2013 that reported HIV prevalence for a total of 3975 adult female sex workers. Only two of the 14 studies were conducted in the last 10 years. The pooled estimate of HIV prevalence was 17.3 % (95 % CI 13.5-21.9 %); however, the prevalence of HIV across individual studies varied considerably (ranging from 0.3 to 32 %) and statistical heterogeneity was substantial (I(2) = 0.89, Q = 123; p < 0.001). Although the variance across the 14 studies was high, prevalence was generally high (10 % or greater in 11 of the 14 included studies). Very few studies have documented the prevalence of HIV among female sex workers in the United States; however, the available evidence does suggest that HIV prevalence among this vulnerable population is high.

Platt, L., et al. (2011). "Risk of sexually transmitted infections and violence among indoor-working female sex workers in London: the effect of migration from Eastern Europe." Sex Transm Infect 87(5): 377-384.

OBJECTIVES: To examine risk factors associated with HIV and sexually transmitted infections (STIs) and experience of physical and sexual violence among sex workers in London, with a particular focus on differences in risk between migrants from Eastern Europe (EE) or the Former Soviet Union (FSU) and UK-born sex workers. METHODS: The authors conducted a cross-sectional survey of sex workers born in the UK, EE or FSU (n = 268), collecting behavioural data, testing for antibodies to HIV and Treponema pallidum, and testing for infection with Chlamydia trachomatis or Neisseria gonorrhoea. FINDINGS: Migrants were younger, saw more clients, and were less likely to use contraception; few reported being coerced into sex work. Overall, prevalence of HIV was 1.1% (95% CI -0.1% to 2.4%), prevalence of syphilis was 2.2% (95% CI 0.4 to 4.0%), and prevalence of infection with chlamydia or gonorrhoea was 6.4% (95% CI 3.2% to 9.6%). Risk factors associated with any infection included having no contact with an outreach worker, age, and having a non-paying sex partner. Increased risk of physical violence from clients was associated with a history of imprisonment or arrest and having a non-paying sex partner. CONCLUSION: Findings suggest an association between outreach services and reduced risk of STIs and between having non-paying partners and increased risk of STIs. Findings also suggest an association between enforcement policies, such as arrest or imprisonment, and drug use and increased risk of physical violence. Interventions are needed to expand outreach, improve uptake of contraceptives for migrants, and reduce levels of violence for all women.

Puri, N., et al. (2017). "Burden and correlates of mental health diagnoses among sex workers in an urban setting." BMC Womens Health 17(1): 133.

BACKGROUND: Women involved in both street-level and off-street sex work face disproportionate health and social inequities compared to the general population. While much research has focused on HIV and sexually transmitted infections (STIs) among sex workers, there remains a gap in evidence regarding the broader health issues faced by this population, including mental health. Given limited evidence describing the mental health of women in sex work, our objective was to evaluate the burden and correlates of mental health diagnoses among this population in Vancouver, Canada. METHODS: An Evaluation of Sex Workers Health Access (AESHA) is a prospective, community-based cohort of on- and off-street women in sex work in Vancouver, Canada. Participants complete interviewer-administered questionnaires semi-annually. We analyzed the lifetime burden and correlates of self-reported mental health diagnoses using bivariate and multivariable logistic regression. RESULTS: Among 692 sex workers enrolled between January 2010 and February 2013, 338 (48.8%) reported ever being diagnosed with a mental health issue, with the most common diagnoses being depression (35.1%) and anxiety (19.9%). In multivariable analysis, women with mental health diagnoses were more likely to identify as a sexual/gender minority (LGBTQ) [AOR=2.56, 95% CI: 1.72-3.81], to use non-injection drugs [AOR=1.85, 95% CI: 1.12-3.08], to have experienced childhood physical/sexual trauma [AOR=2.90, 95% CI: 1.89-4.45], and work in informal indoor [AOR=1.94, 95% CI: 1.12 - 3.40] or street/public spaces [AOR=1.76, 95% CI: 1.03-2.99]. CONCLUSIONS: This analysis highlights the disproportionate mental health burden experienced by women in sex work, particularly among those identifying as a sexual/gender minority, those who use drugs, and those who work in informal indoor venues and street/public spaces. Evidence-informed interventions tailored to sex workers that address intersections between trauma and mental health should be further explored, alongside policies to foster access to safer workspaces and health services.

Rogers, B. G., et al. (2021). "Sex Workers and Syndemics: A Population Vulnerable to HIV and COVID-19." Arch Sex Behav 50(5): 2007-2016.

COVID-19 has disproportionately affected vulnerable populations across the U.S. Street-based sex workers are one vulnerable population whose health and impact of COVID-19 have been understudied to date. The goal of this study was to evaluate findings from a community needs assessment with street-based sex workers on impact of COVID-19 on health behaviors and social circumstances. A brief survey was developed at a community-based harm reduction and recovery services organization. Surveys were administered by peer specialists to street-based sex workers during street outreach in April and May 2020. A total of 46 surveys were analyzed. Many individuals reported continuing to do sex work and use substances during the COVID pandemic. Slightly more than a quarter of individuals (n = 13; 28.3%) indicated using personal protective equipment while doing sex work and described challenges to using precautions when working with clients. Individuals had used marijuana (n = 32, 71.1%), cocaine (n = 17, 39.5%), prescription stimulants (n = 9, 21.4%), methamphetamines (n = 5, 11.9%), prescription opioids (n = 12, 27.3%), street opioids (n = 12, 27.3%), sedatives (n = 11, 25.0%), hallucinogens (n = 3, 6.8%), inhalants (n = 3, 7.0%), or some other substance (n = 4, 8.7%) in the past 30 days. About half (48.8%) reported that COVID-19 had a major impact on their lives. This study is among the first to characterize the impact of COVID-19 on street-based sex workers. From a public health standpoint, this group also represents a high-priority population given their vulnerability and close contact with others, which increases the potential for community spread.

Shannon, K., et al. (2018). "The global response and unmet actions for HIV and sex workers." Lancet 392(10148): 698-710.

Female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018. 4 years since our Lancet Series on HIV and sex work, our updated analysis of the global HIV burden among female sex workers shows that HIV prevalence is unacceptably high at 10·4% (95% CI 9·5-11·5) and is largely unchanged. Comprehensive epidemiological data on HIV and antiretroviral therapy (ART) coverage are scarce, particularly among transgender women. Sustained coverage of treatment is markedly uneven and challenged by lack of progress on stigma and criminalisation, and sustained human rights violations. Although important progress has been made in biomedical interventions with pre-exposure prophylaxis and early ART feasibility and demonstration projects, limited coverage and retention suggest that sustained investment in community and structural interventions is required for sex workers to benefit from the preventive interventions and treatments that other key populations have. Evidence-based progress on full decriminalisation grounded in health and human rights-a key recommendation in our Lancet Series-has stalled, with South Africa a notable exception. Additionally, several countries have rolled back rights to sex workers further. Removal of legal barriers through the decriminalisation of sex work, alongside political and funding investments to support community and structural interventions, is urgently needed to reverse the HIV trajectory and ensure health and human rights for all sex workers.

Taylor, A., et al. (2008). "Prevalence and determinants of hepatitis C virus infection among female drug injecting sex workers in Glasgow." Harm Reduct J 5: 11.

BACKGROUND: Few studies of the prevalence of hepatitis C virus (HCV) infection have focussed on women who work as street sex workers to finance their drug use. METHODS: The investigators report the survey findings of such a population in Glasgow. All women attending the health and social care drop-in centre, situated in Glasgow's "Red Light Area", during a four-week period in 1999 were invited to participate in a survey involving the provision of a saliva sample for anonymous HCV testing and the self-completion of a questionnaire seeking demographic, sexual and injecting practice data. RESULTS: Of the 223 women who attended, 51% agreed to participate. Of the 98 women who provided a sufficient saliva sample, 64% (95% CI: 54%-74%) tested HCV antibody positive; 98% of those who tested positive had ever injected drugs. Adjusting for the 85% sensitivity of the saliva test, the HCV antibody prevalence among IDU sex workers sampled was 81%; a rate which is considerably higher than those recorded, contemporaneously, among Glasgow IDUs generally. Two factors were independently associated with HCV antibody positivity in saliva: ever shared needles and syringes (adjusted OR 5.7, 95% CI 2-16) and number of times imprisoned (adjusted OR 7.3, 95% CI 1.4-39, for more than five times compared to zero times). CONCLUSION: Women who engage in street sex work to finance their drug habit are a particularly desperate, chaotic and vulnerable population. This study demonstrates that their HCV infection risk may be greater than that for other IDUs. Those responsible for designing interventions to prevent HCV infection among IDUs should consider the special needs of this group.

Treloar, C., et al. (2021). "Rethinking the relationship between sex work, mental health and stigma: a qualitative study of sex workers in Australia." Soc Sci Med 268: 113468.

AIMS: Sex workers may experience stigma both related to their occupation as well as to mental health issues that they face. There is limited research on the lived experience of sex workers managing mental health and stigma. This study examined the experiences of sex workers in Australia in relation to stigma surrounding sex work, and sex workers' mental health, including self-management and experiences of accessing mental health services. METHOD: Six focus groups and two interviews were conducted with 31 sex workers. Data collection was co-moderated by a sex worker and a university-based researcher. Analysis was informed by an approach which positioned sex workers as agential and capable, and which drew attention to structural aspects of stigma. RESULTS: Sex workers identified that the stigma surrounding their profession had a significant impact on their mental health. The need to manage risks through selective disclosure of sex work was a pervasive experience. Management of mental health and the stigma associated with sex work was described as a responsibility primarily of the individual through self-care activities and occasional access to mental health services. Participants reported poor treatment from mental health practitioners who saw sex workers as victims lacking agency, imposed beliefs that sex work was the pathological root cause of mental health issues, or approached the issue with fascination or voyeurism. Other presenting issues (especially mental health) were lost or obscured in therapeutic encounters resulting in suboptimal care. CONCLUSION: The threat of stigma is pervasive and has mental health implications for sex workers. Our findings point to the need for increased training and capacity development for mental health practitioners, funding for peer support services to ameliorate internalised stigma, and action from governments to introduce enabling legal environments, stigma reduction programs and structural protections from sex work stigma.

Viswasam, N., et al. (2021). The Epidemiology of HIV Among Sex Workers Around the World: Implications for Research, Programmes, and Policy.  In : Sex Work, Health, and Human Rights: Global Inequities, Challenges, and Opportunities for Action. Goldenberg, S. M., Morgan Thomas, R., Forbes, A. etBaral, S. Cham (CH), Springer

Globally, sex workers of all genders and identities continue to face disproportionately high burdens of HIV, demonstrating the need for programmes better tailoring services to their unmet needs. The reasons for this high burden are complex, intersecting across behavioural, social, and structural realities experienced by sex workers. Here, we build on systematic reviews of HIV among sex workers and case studies rooted in sex workers’ lived experience to describe: (1) the global HIV burden among sex workers; (2) the factors and determinants that influence the HIV burden; (3) intervention coverage and gaps to reduce HIV-related inequities faced by sex workers, over the past decade. Sex workers living with HIV have not benefited enough from significant increases in HIV treatment among the general population. Engagement in this HIV treatment cascade is hindered by structural factors including stigma, migration, policing, criminalisation, and violence, as well as substance use, which present increasingly concurrent risks with HIV among sex workers. Emerging biomedical HIV prevention innovations exist to support the health and human rights of sex workers and reduce onward transmission risk, but persistent data gaps remain, and should be addressed via community-driven implementation research. Epidemiologic research engaging sex workers who are cismen and transgender persons is similarly crucial. Community empowerment approaches have reduced the odds of HIV infection, highlighting the case for greater investments in structural interventions. These investments, combined with filling data gaps and national action towards sex work decriminalisation alongside legal protections, are critical to achieving reductions in sex workers’ HIV burden.

Zermiani, M., et al. (2012). "Prevalence of sexually transmitted diseases and hepatitis C in a survey of female sex workers in the north-East of Italy." Open AIDS J 6: 60-64.

A key issue in the prevention and control of Sexually Transmitted Diseases (STD) is to provide access to health centres, and in diagnosing and treating STD. The present study is aimed to assess the prevalence of sexually transmitted diseases (STDs) and Hepatitis C virus (HCV) in a population of immigrant female sex workers (FSWs). We conducted a cross sectional survey of FSWs working in Verona, North-eastern Italy. Screening test included serology for STDs [including Human Immunodeficiency Virus (HIV), syphilis and Hepatitis B virus (HBV)] and hepatitis C virus (HCV).Sixteen out of 345 (4.6%) street FSWs screened during 1999-2007 resulted positive for HIV, 12 (3.5%) were positive for HBsAg, 7 (2.0%) were positive for syphilis serological test, and 3 (0.9%) were positive for HCV. Comparison of the prevalence data between women from Africa (286/345, 82.8%) and other countries showed no statistical difference for HIV infection (R.R. 1.44; 95% CI, 0.34-6.19) and for presence of HBsAg (R.R. 2.27; 95% CI, 0.30-17.24). The positivity of syphilis serologic tests had a lower prevalence among African FSWs (mostly coming from Nigeria) than among FSWs from Eastern Europe (57/345, 16.5%). This difference was statistically significant (R.R. 0.03; 95% CI, 0.00-0.28). The prevalence of HIV infection increased with age (p=0.04, by chi2 for trend analysis), but not with the time worked as sex workers in Italy. Moreover, the presence of any of the screened infections was predictable by both age and earlier time of immigration by way of logistic multivariable regression.The prevalence of HIV and HBsAg was higher in the whole analyzed cohort compared to the general population; prevalence of syphilis was significantly higher in FSWs from Eastern Europe than in FSWs from Africa. HCV prevalence remains low among non intravenous drug abuser FSWs. The data offers a starting point to address targeted intervention that would prevent FSWs acquiring and transmitting STDs.

Obstacles et interventions facilitant l'accès aux services de santé

Revues de littérature

Aggarwal, N. K., et al. (2021). "Health and Health Care Access Barriers Among Transgender Women Engaged in Sex Work: A Synthesis of U.S.-Based Studies Published 2005-2019." LGBT Health 8(1): 11-25.

Purpose: Transgender women (TW) are likely to experience job discrimination and engage in commercial sex transactions. As a group, they have the highest risk for HIV/AIDS. However, little is known about the health needs of transgender women sex workers (TWSW) in the United States and the structural and psychosocial barriers to their health care access. The objective of this systematic review was to systematically document these needs and barriers by using a framework approach. Methods: We searched PubMed, JSTOR, and Google Scholar for primary and secondary studies published in 2005-2019 that addressed the health of TWSW in the United States. We used a standardized data extraction form to gather data from eligible articles. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to assess study quality. Results: Fifty-three articles met the inclusion criteria, including mentioning health-related topics among TWSW. More articles appeared in recent years. Most studies collected data with convenience samples in urban areas. Structural barriers reported included transphobia, lack of pre-exposure prophylaxis targeted at TW, and lack of health insurance coverage. Psychosocial barriers included distrust of the health care system, self-esteem, alcohol and substance use, and mental health. Conclusions: TWSW have unique health care needs that are not being addressed due to barriers to health care access. More research is required to identify non-HIV-related health burdens and details about psychosocial barriers to health care access.

(2021). "Correction to: Health and Health Care Access Barriers Among Transgender Women Engaged in Sex Work: A Synthesis of U.S.-Based Studies Published 2005-2019 by Aggarwal et al. LGBT Health 2021;8(1):11-25; DOI: 10.1089/lgbt.2019.0243." LGBT Health 8(7): 502.

Brookfield, S., et al. (2020). "Barriers to Accessing Sexual Health Services for Transgender and Male Sex Workers: A Systematic Qualitative Meta-summary." AIDS Behav 24(3): 682-696.

Access to safe and effective sexual healthcare services for transgender and male sex workers (TMSW) is a human right. Globally, TMSW experience a higher prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections than the general population or other sex workers, suggesting the existence of unique challenges for this group when accessing healthcare. A systematic database search identified 22 qualitative papers addressing barriers to accessing sexual healthcare services for TMSW. These papers were critically evaluated for adherence to best practice standards for qualitative research and research with sex workers. A coding process identified five themes. Stigma was the predominant barrier, and was divided into stigma related to sexuality, gender identity, HIV status, sex worker status, and internalised stigma. Other barriers were confidentiality concerns, sexual health literacy, fatalism, and structural barriers. Each of these themes were informed by the wider context of stigma. The literature presents a complex syndemic of social disadvantage and exclusion acting to produce and reinforce health disparities related to sexual health and access to screening and treatment for TMSW.

Davey, C., et al. (2018). "The effect of mobility on HIV-related healthcare access and use for female sex workers: A systematic review." Soc Sci Med 211: 261-273.

Female sex workers (FSW) experience a high HIV burden and are often mobile. FSW access to HIV-related healthcare is essential for equitable welfare and to reduce new HIV infections. We systematically reviewed the literature on mobility and HIV-related healthcare access and use among FSW. Outcome measures included: HIV/STI testing, STI treatment, PrEP (initiation or adherence), and ART (initiation or adherence). We summarised the results with a narrative synthesis. From 7417 non-duplicated citations, nine studies from Canada (3), Guatamala, Honduras (2), India, South Africa, and Vietnam were included. Only one of the studies was designed to address mobility and healthcare access, and only six reported adjusted effect estimates. Mobility was measured over four time-frames (from 'current' to 'ever'), as having lived or worked elsewhere or in another town/province/country. Three studies from Canada, Guatemala, and India found mobility associated with increased odds of poor initial access to healthcare (adjusted odds ratios (AOR) from 1.33, 95% CI 1.02, 1.75, to 2.27, 95% CI 1.09, 4.76), and one from Vietnam found no association (odds ratio (OR): 0.92, 95% CI 0.65, 1.28). The study from South Africa found no association with initiating ART (risk ratio: 0.86, 95% CI 0.65, 1.14). Two studies from Canada and Honduras found increased odds of ART interruption (AOR 2.74, 95% CI 0.89, 8.42; 5.19, 95% CI 1.38, 19.56), while two other studies from Canada and Honduras found no association with detectable viral load (OR 0.84, 95% CI 0.08, 8.33; AOR 0.79, 95% CI 0.41, 1.69). We found that mobility is associated with reduced initial healthcare access and interruption of ART, consistent with literature from the general population. Discordance between effects on adherence and viral load may be due to measurement of mobility. Future research should carefully construct measures of mobility and consider a range of HIV-related healthcare outcomes.

Hallett, N. (2023). "Healthcare interventions for sex workers: protocol for a scoping review." BMJ Public Health 13(8): e074983.

INTRODUCTION: Sex workers, who provide sexual or erotic acts in exchange for payment, often experience multiple disadvantages, including mental ill health and substance misuse. Mainstream healthcare services are generally not configured to facilitate engagement with sex workers and therefore, services are needed that are accessible to this population. The aim of this scoping review is to understand the evidence base for approaches, services and interventions that are aimed at addressing sex workers' health needs. METHODS AND ANALYSIS: Nine databases, CINAHL, Embase, EThOS, Google Scholar, Health Management Information Consortium, MEDLINE, ProQuest Dissertations and Theses, PsycINFO and Web of Science (Core Collection), will be searched, with results limited to English language publications and those published from 2003 onwards. De-duplication, study selection and data extraction will be conducted using Covidence software. Included studies will describe or evaluate approaches, services or interventions that address the health needs of sex workers who offer services that involve physical contact with a client. ETHICS AND DISSEMINATION: No ethical review is needed. The final report will be shared with Birmingham City Council as part of ongoing work and will be disseminated by peer-reviewed publication. STUDY REGISTRATION: Open Science Framework (doi: 10.17605/OSF.IO/N7WSX).

Johnson, L., et al. (2025). "Outreach health-care services for people experiencing exclusion in high-income countries." Lancet Public Health 10(9): e784-e793.

Inclusion health aims to prevent and address health and social inequalities for people experiencing exclusion, such as people experiencing homelessness, people who have a history of contact with the criminal justice system, people who use drugs, sex workers, vulnerable migrants, victims of modern slavery and human trafficking, and Romany Gypsy, Roma, and Travellers communities. These populations have poor health outcomes and disproportionate health inequities, partly resulting from inadequate health-care access. Outreach services can improve health-care access, but there is little evidence of how outreach operates successfully. We conducted a realist review of multicomponent outreach health-care services to understand the circumstances under which outreach works for people experiencing exclusion and why. Key components of effective outreach include person-centred services and appointments, staff expertise, high-quality communication, and close partnership with people experiencing exclusion and relevant organisations. Service users are likely to develop trust and further engage through positive experiences and regular interaction with the same staff.

Ma, P. H. X., et al. (2017). "The Socio-Ecological Model Approach to Understanding Barriers and Facilitators to the Accessing of Health Services by Sex Workers: A Systematic Review." AIDS Behav 21(8): 2412-2438.

Inequities in accessing health care persist among sex workers. The purpose of the review is to understand the health-seeking behaviours of sex workers and their access to health care services with socio-ecological model. Of 3852 citations screened, 30 met the inclusion criteria for this review. The access that sex workers have to health services is a complex issue. A wide range of barriers and facilitators at multiple levels could influence sex workers' utilization of health care services, such as health or service information, stigma, social support, quality of health care, available, accessible and affordable services, healthcare policy. Health services or future intervention studies should take into account the facilitators and barriers identified in this review to improve the health services utilization and health of sex workers, as part of the effort to protect the right of humans to health.

McBride, B., et al. (2021). "Structural determinants of HIV/STI prevalence, HIV/STI/sexual and reproductive health access, and condom use among immigrant sex workers globally." Aids 35(9): 1461-1477.

OBJECTIVE: Given stark health inequities among precarious and criminalized workers, we aimed to apply a structural determinants framework to systematically review evidence on HIV/sexually transmitted infection (STI) prevalence, access to HIV/STI/SRH services, and condom use among im/migrant sex workers (ISWs) globally. METHODS: Systematic search of peer-reviewed studies published in English (2009-2019). Eligible studies reported HIV/STI, access to HIV/STI/SRH services, and/or condom use outcomes and/or lived experiences among ISWs. Quantitative and qualitative data were synthesized using a structural determinants framework. RESULTS: Of 425 studies screened, 29 studies from 15 countries were included. HIV prevalence ranged from 0.3 to 13.6% and varied across settings, with highest prevalence among undocumented ISWs in a high-income country (Portugal). Precarious immigration status was a structural factor associated with poorer HIV/STI outcomes, whereas qualitative narratives showed ISWs' lived experiences as strongly shaped by policing and stigma. Despite disparities, in some settings, HIV and STI prevalence were lower and odds of condom use with clients were higher among ISWs relative to non-im/migrant sex workers. This review identified a paucity of research on SRH and male and gender-diverse ISWs. Across legislative settings, criminalization of SW and im/migrant status, policing, and migration-related marginalization were prominent structural barriers to ISWs' HIV/STI/SRH access. CONCLUSION: This review identified important inequities and variation in HIV/STI prevalence among ISWs globally. Our findings highlight impacts of the intersections of migration and criminalization, and suggest a need to reform criminalized sex work laws; address punitive policing and immigration enforcement; enable safer indoor work environments; and expand community-based interventions towards promoting HIV/STI/SRH access and health equity among ISWs.

Nnko, S., et al. (2019). "Determinants of access to HIV testing and counselling services among female sex workers in sub-Saharan Africa: a systematic review." BMC Public Health 19(1): 15.

BACKGROUND: HIV testing and counselling (HTC) is an essential component for HIV prevention and a critical entry point into the HIV continuum of care and treatment. Despite the importance of HTC for HIV control, access to HTC services among female sex workers (FSWs) in sub-Saharan Africa (SSA) remains suboptimal and little is known about factors influencing FSWs' access to HTC. Guided by the client-centred conceptual framework, we conducted a systematic review to understand the facilitators and barriers influencing FSWs in SSA to access HTC services. METHODS: A systematic search was conducted in MEDLINE, POPLINE and Web of Science databases for literature published between January 2000 and July 2017. References of relevant articles were also searched. We included primary studies of any design, conducted in SSA and published in the English language. Studies conducted in multi-sites inclusive of SSA were included only if data from sites in SSA were separately analysed and reported. Similarly, studies that included other subpopulations were only eligible if a separate analysis was done for FSWs. This review excluded papers published as systematic reviews, editorial comments and mathematical modelling. The protocol for this review is registered in the Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42017062203. RESULTS: This review shows that factors related to approachability, acceptability, availability, affordability and appropriateness of the services are crucial in influencing access to HTC services among FSWs in SSA. These factors were mediated by individual attributes such as HIV risk perceptions, awareness of the availability of HTC, and perceptions of the importance and quality of HTC services. The decision to utilise HTC was predominantly hampered by discriminatory social norms such as HIV stigma and criminalisation of sex work. CONCLUSIONS: FSWs' access to HTC is facilitated by multiple factors, including individual awareness of the availability of HTC services, and perceived quality of HTC especially with regard to assured confidentiality. Concerns about HIV stigma and fear about discrimination due to community intolerance of sex work acted as major barriers for FSWs to seek HTC services from the facilities offering health services to the general population.

Moore, B. E., et al. (2023). "Maternal health and maternal health service utilization among female sex workers: A scoping review." WOMENS HEALTH 19.

Background:High proportions of female sex workers (FSWs) become pregnant and have children. Many FSWs are at increased risk of maternal health complications due to factors such as poverty, violence, and healthcare barriers. Despite this, FSWs' maternal health and use of maternal health services (MHS) receive limited attention.Objectives:The objectives of this scoping review are to (1) synthesize existing data on FSWs' maternal health and MHS utilization and (2) assess the state of peer-reviewed literature on FSWs' maternal health in regard to methodological approaches and reported outcomes. Eligibility criteria:Included articles were peer-reviewed, published in English, and reported empirical data on FSWs for outcomes related to antenatal care, pregnancy, and labor complications, postnatal and delivery care, and/or barriers to MHS.Sources of evidence: Article searches were conducted in PubMed, Web of Science, Global Health, Sociological Abstracts, Sociological Index, PsychInfo, and CINAHL Charting methods: Information extracted from eligible articles included publication year, study design, location, sample size, outcome measures, and findings. The "Three Delays" model was used to synthesize findings on barriers to MHS as relevant to phase I, II, or III delays. Results:Eighteen publications met the eligibility criteria. Studies were conducted in 11 countries and primarily reported quantitative data from cross-sectional surveys. The most frequently reported outcome was antenatal care utilization (n = 14), whereas few studies reported findings related to postnatal care and breastfeeding counseling (n = 2). Across publications, there was a substantial range in the proportion of FSWs who reported accessing different types of MHS. Conclusion: Literature on FSWs' maternal health is limited and heterogenous. More research is needed that specifically focuses on measuring outcomes related to FSWs' maternal health and examines associated factors. Such work can inform future research directions and public health interventions for FSWs-a population of marginalized women whose maternal health has been overlooked in existing efforts.

Oldenburg, C. E., et al. (2014). "Global burden of HIV among men who engage in transactional sex: a systematic review and meta-analysis." PLoS One 9(7): e103549.

BACKGROUND: Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts. METHODS: We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004-2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men. FINDINGS: Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5). CONCLUSIONS: The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.

Stoner, M. C. D. et Rucinski, K. B. (2022). "Differentiating the incidence and burden of HIV by age among women who sell sex: a systematic review and meta-analysis."  25(10): e26028.

INTRODUCTION: Young women who sell sex (YWSS) are at heightened risk of HIV acquisition and transmission and are among the least engaged in HIV services. There is insufficient epidemiologic evidence characterizing the burden of HIV among YWSS, particularly as compared to older WSS. These data are needed to design and tailor effective HIV prevention and treatment programmes for this population. METHODS: We conducted two parallel systematic reviews and meta-analyses to define both the immediate and long-term HIV risks for YWSS, including among women engaged in sex work, survival sex and transactional sex. In the first review, we identified and synthesized published studies of HIV incidence comparing estimates for cisgender women ≤24 years of age versus &gt;24. In the second review, we identified and synthesized studies of HIV prevalence, comparing estimates for cisgender women who initiated selling sex &lt;18 versus ≥18 years. In both reviews, we completed a search of four databases for articles in any language and any geographic area published from 1 January 1980 until 12 February 2021. Included articles were assessed for quality and a random effects model was used to calculate pooled effect estimates for each review. RESULTS AND DISCUSSION: We identified 12 studies for the HIV incidence review and 18 studies for the HIV prevalence review. In a meta-analysis, HIV incidence was elevated in younger (5.3 per 100 person-years [PY]; 95% confidence interval [CI]: 3.5, 7.1) compared to older women (2.8 per 100 PY; 95% CI: 1.7, 3.9), although CIs overlapped. HIV prevalence among those who initiated selling sex &lt;18 years of age (28.8; 95% CI: 18.9, 38.7) was higher than those who initiated later (20.5; 95% CI: 12.4, 28.6). CONCLUSIONS: These companion reviews offer an important perspective on the relative HIV risk of engaging in selling sex at a younger age. Our findings highlight the unique and intersectional challenges YWSS face, and the importance of ensuring that health services are tailored to meet their specific needs. Research and programming should routinely stratify data into meaningful age bands to differentiate and intervene within this population.

Turner, K. et Meyrick, J. (2022). "Which psychosocial interventions improve sex worker well-being? A systematic review of evidence from resource-rich countries."  48(e1): e88-e100.

OBJECTIVE: To establish the state of the evidence base around psychosocial interventions that support well-being in sex workers in order to inform policy and practice within a resource-rich geographical context. METHODS: Published and unpublished studies were identified through electronic databases (PsychINFO, CINHAL Plus, MEDLINE, EMBASE, The Cochrane Library and Open Grey), hand searching and contacting relevant organisations and experts in the field. Studies were included if they were conducted in high-income settings with sex workers or people engaging in exchange or transactional sex, and evaluated the effect of a psychosocial intervention with validated psychological or well-being measures or through qualitative evaluation. RESULTS: A total of 19 202 studies were identified of which 10 studies met the eligibility criteria. The heterogeneity found dictated a narrative synthesis across studies. Overall, there was very little evidence of good quality to make clear evidence-based recommendations. Despite methodological limitations, the evidence as it stands suggests that peer health initiatives improve well-being in female street-based sex workers. Use of ecological momentary assessment (EMA), a diary-based method of collecting real-life behavioural data through the use of twice-daily questionnaires via a smartphone, increased self-esteem and behaviour change intentions. CONCLUSIONS: Work with sex workers should be based on an evidence-based approach. Limitations to the existing evidence and the constraints of this work with vulnerable groups are recognised and discussed.

Xu, W., et al. (2023). "Facilitators and Barriers for Chlamydia and Gonorrhea Testing in Female Sex Workers: A Scoping Review." Open Forum Infect Dis 10(8): ofad397.

We conducted a scoping review to examine the barriers and facilitators accessing Chlamydia trachomatis and Neisseria gonorrhoeae testing among female sex workers. A literature search was conducted in Embase, Medline, and Web of Science for studies published from the date of creation of database to 17 March 2023, without restrictions for publication date. We used thematic synthesis to identify common affecting factors across included studies and then linked them into categories of the socioecological framework. Among the 14 articles included, 3 utilized qualitative methods, 7 utilized quantitative surveys, 2 were mixed methods, and 2 were randomized controlled trials. Several important affecting factors stood out during this review, including stigma and discrimination, as well as social support at the societal level, and financial costs at the service level. This review suggested that interventions on addressing societal- and service-level determinants are needed, which includes reducing stigma and discrimination toward sex work and cost for facility testing, as well as increasing social support and community engagement.

En France

Angoumis, K., et al. (2023). "Reducing the Burden of HIV and HCV among Sex Workers Who Use Drugs in France." South Eastern European Journal of Public Health: 113-131.

https://doi.org/10.56801/seejph.vi.373

Context: The far-reaching effects of the Covid-19 pandemic exacerbated the adverse working and living conditions of Sex Workers (SWs) in France. These consequences, coupled with illicit drug use, and reduced access to prevention measures raise concerns for the transmission of the Human Immunodeficiency virus (HIV) and Hepatitis C virus (HCV) among Sex Workers Who Use Drugs (SWWUD), creating an urgent call for targeted interventions. There is an acute need for accessible, ongoing care for SWWUD to prevent HIV and HCV infections and mitigate adverse health effects. Current French health services such as harm reduction and HIV/HCV prevention services often operate separately and seldom address SWs and People Who Use Drugs (PWUD) simultaneously. Given the compounding set of challenges that SWWUD face, a holistic approach to policy interventions must be considered. Policy Options: Firstly, integrated services are particularly effective in promoting harm reduction and improving the health of their users. When these services include substance use care and HIV services, uptake of these interventions and primary care utilisation increases due to enhanced accessibility. Secondly, pre-exposure prophylaxis (PrEP) and needle and syringe programs (NSP) are clinically effective prevention methods that, when coupled with point-of-care-testing (POCT), can reduce the prevalence of HIV and HCV and improve the monitoring of these viruses. Finally, willingness to engage with health services is impacted by the attitudes of healthcare staff. Sensitisation training can promote trauma-informed care, a non-judgemental approach in health workers, encouraging SWWUD to seek care and achieve better health outcomes. Recommendations: A three-pronged approach to implementing integrated services is recommended. First, facilitating access to care can be attained through the linkage of patients to treatment, primary care, sexual and reproductive health, and social services. Existing service providers can be supported with interdisciplinary teams and telemedicine to reduce care fragmentation. Additionally, prevention and testing measures can be enhanced through the coordinated provision of needle and syringe programs, point-of-care testing, PrEP, and harm reduction supplies. These services should be linked to established integrated service centres to ensure a continuum of care. Finally, peer leaders may deliver sensitisation training for service providers to reduce stigma and improve understanding of the unique health needs of SWWUD. Integrated service providers should further employ peer leaders as peer navigators to promote the vision of community empowerment and inclusion.

Atramont, A. et Le Vu, S. (2014). "Analyse du public touché par l'expérimentation Flash-Test 2013. Une semaine de dépistage du VIH dans quatre régions françaises". Saint-Maurice Institut de veille sanitaire

https://www.santepubliquefrance.fr/content/download/182562/2307310

[BDSP. Notice produite par InVS I9pr8R0x. Diffusion soumise à autorisation]. Une semaine de dépistage rapide du VIH (Flash-Test) a été organisée en 2013 dans 4 régions particulièrement concernées par l'épidémie : Ile-de-France, Provence-Alpes-Côte d'Azur (Paca), Rhône-Alpes et Guyane. Un questionnaire proposé aux personnes dépistées a permis d'analyser le public touché par cette intervention. L'analyse a porté sur 8 713 personnes. Le public était principalement masculin et jeune. Les participants étaient pour 38% d'entre eux nés à l'étranger. Les hommes ayant des rapports sexuels avec des hommes représentaient près de 15% de la population testée, les usagers de drogues par voie injectable 2,4%, et les personnes transgenres 0,3%. Les répondants avaient pour 64% déjà eu un test VIH au cours de la vie. Au cours de la semaine, 48 personnes ont découvert leur séropositivité au VIH, soit un taux de 0,55%. Par rapport aux actions de dépistage communautaire mises en place en 2011, l'intervention a relativement moins touché les populations particulièrement exposées au VIH. Les participants de Flash-Test n'étaient pas particulièrement éloignés du dispositif de dépistage. Enfin, la capacité à dépister des personnes séropositives était similaire à celle du dispositif des CDAG/Ciddist (Consultation de dépistage anonyme et gratuit/Centre d'information, de dépistage et de diagnostic des infections sexuellement transmissibles), voire plus basse pour la Guyane. L'opération Flash-Test a probablement constitué un apport en termes de mobilisation des acteurs du dépistage et de visibilité auprès du public du dépistage du VIH et des tests rapides. Néanmoins, l'analyse des caractéristiques des participants ne permet pas d'identifier une plus-value en termes épidémiologiques de ce modèle par rapport au dispositif de dépistage existant. (R.A.).

Beaure d’Augères, M. et Charles, R. (2025). "Transidentité et travail du sexe : dynamiques sociales et enjeux de santé. Première partie : Enfance, découverte de la transidentité." Médecine : de la médecine factuelle à nos pratiques 21(4): pp.166-170.

Cette monographie explore les vies de trois personnes transgenres engagées dans le travail du sexe (TDS). Autour de ces entretiens semi-dirigés, l’étude met en évidence des problématiques médicales et sociales multiples, notamment des difficultés d’accès aux soins, les stigmatisations et les préjugés professionnels. Les discriminations impactent de manière significative de nombreux aspects de leur vie quotidienne, comme leur santé mentale, leurs relations sociales et leur stabilité économique. La première partie aborde comment s’est construite la transidentité de Léa. (R.A.)

Beaure d’Augères, M. et Charles, R. (2025). "Transidentité et travail du sexe : dynamiques sociales et enjeux de santé. Deuxième partie : expériences dans le système de soins." Médecine : de la médecine factuelle à nos pratiques 21(5): pp.220-224.

Cette monographie explore les vies de trois personnes transgenres engagées dans le travail du sexe (TDS). Autour de ces entretiens semi-dirigés, l’étude met en évidence des problématiques médicales et sociales multiples, notamment des difficultés d’accès aux soins, les stigmatisations et les préjugés professionnels. Cette deuxième partie met en lumière l’importance d’initiatives systémiques pour répondre aux besoins de santé spécifiques des personnes transgenres.

Beaure d’Augères, M. et Charles, R. (2025). "Transidentité et travail du sexe : dynamiques sociales et enjeux de santé. Troisième partie : Le travail du sexe." Médecine : de la médecine factuelle à nos pratiques 21(6): pp.263-268.

Cette monographie explore les vies de trois personnes transgenres engagées dans le travail du sexe (TDS). Autour de ces entretiens semi-dirigés, l’étude met en évidence des problématiques médicales et sociales multiples, notamment des difficultés d’accès aux soins, les stigmatisations et les préjugés professionnels. Cette troisième partie appelle à une sensibilisation accrue, à la lutte contre les discriminations et à la mise en place de politiques inclusives afin de garantir un accès aux soins respectueux et sécurisé pour les personnes trans travailleuses du sexe. (R.A.)

Blanc, A., et al. (2023). "Travailleuses* du sexe aux urgences: quand le tabou entrave les soins [Sex workers: when taboos get in the way of care in the emergency department]." Revue medicale suisse 19(837): 1466-1469.

En Suisse, le travail du sexe est légal sous certaines conditions depuis 1942 et le nombre de travailleuses du sexe (TS) en 2011 était estimé entre 14 000 et 20 000 sur l’entier du territoire, dont 96 % de migrantes. Ces personnes sont exposées à de nombreuses vulnérabilités, de par leur métier mais également en raison de lacunes structurelles et institutionnelles. La complexité de leur prise en charge a mené au fil du temps à la création de structures et d’unités spécialisées, qui sont souvent méconnues des professionnels de la santé. L’objectif de cet article est de mettre en lumière ces lieux et de proposer aux soignants des conseils adaptés afin d’améliorer la prise en charge des TS au service d’urgences.

Calin, R., et al. (2020). "Acceptability of on-site rapid HIV/HBV/HCV testing and HBV vaccination among three at-risk populations in distinct community-healthcare outreach centres: the ANRS-SHS 154 CUBE study." BMC Infect Dis 20(1): 851.

BACKGROUND: HIV, HBV and HCV infections continue to represent major health concerns, especially among key at-risk populations such as men who have sex with men (MSM), people who inject drugs (PWIDs), transgender women (TGW) and sex workers (SW). The objective of the ANRS-CUBE study was to evaluate the acceptability of a healthcare, community-based strategy offering a triple rapid HIV-HBV-HCV testing, and HBV vaccination, targeted at three priority groups (MSM, PWIDs and TGW/SWs), in three community centers, in the Paris area. METHODS: This longitudinal multicentric non-randomized study included all adult volunteers attending one of the three specialized community centers in Paris, between July 2014 and December 2015. HIV, HBV and HCV status and acceptability of HBV vaccination were evaluated. RESULTS: A total of 3662, MSM, 80 PWIDs and 72 TGW/SW were recruited in the three centers respectively. Acceptability of rapid tests was 98.5% in MSM and 14.9% in TGW/SWs, but could not be estimated in PWIDs since the number of users attending and the number of proposals were not recorded. User acceptability of HBV vaccination was weak, only 17.9% of the eligible MSM (neither vaccinated, nor infected) agreed to receive the first dose, 12.2% two doses, 5.9% had a complete vaccination. User acceptability of HBV vaccination was greater in PWIDs and TGW/SWs, but decreased for the last doses (66.7 and 53.3% respectively received a first dose, 24.4 and 26.7% a second dose and 6.7 and 0% a third dose). Fifty-three participants (49 MSM and 4 PWIDs) were discovered HIV positive, more than half with a recent infection. All but two HIV positive participants were linked to appropriate care in less than one month. CONCLUSIONS: Rapid HIV-HCV-HBV screening showed a very high level of acceptability among MSM. Efforts need to be made to improve immediate acceptability for HBV vaccination, especially among MSM, and follow-up doses compliance. Our results show the important role of community centers in reaching targets, often fragile, populations, while also suggesting the need to reinforce on-site human support in terms of testing and vaccination, especially when addressing PWIDs.

Chappuis, M., et al. (2017). "Observatoire de l'accès aux soins de la mission France de Médecins du Monde. Rapport 2016", Médecins du Monde.

[BDSP. Notice produite par ORSMIP p988R0xJ. Diffusion soumise à autorisation]. L'Observatoire de l'accès aux soins de la Mission France a été créé en 2000 pour témoigner des difficultés d'accès aux dispositifs de droit commun des populations accueillies par l'association. L'Observatoire constitue un outil de connaissance sur les populations vulnérables, par ailleurs ignorées des statistiques officielles de santé publique, mais également de pilotage des programmes de l'association et de plaidoyer. Il permet d'élaborer des propositions au regard de données objectives et de l'expertise de terrain, à partir desquelles MdM interpelle les acteurs politiques, institutionnels et/ou professionnels de santé pour améliorer l'accès aux droits et aux soins des populations précaires ou en situation d'exclusion. En 2016, Médecins du Monde compte 68 programmes dans plus d'une trentaine de villes auprès des personnes en situation de grande précarité et/ou d'exclusion, dont l'objectif est de promouvoir ou faciliter leur accès aux droits et aux soins. Les équipes constatent au quotidien les difficultés auxquelles sont confrontées ces populations et s'attachent à faire valoir leurs droits, en assurer la continuité dans le temps et leur faciliter un accès aux soins.

Chappuis, et al. (2015). "Observatoire de l'accès aux soins de la mission France de Médecins du Monde. Rapport 2015". Paris : Médecins du Monde Mission France - Observatoire de l'Accès aux Soins

L'Observatoire de l'accès aux soins de Médecins du Monde est un outil essentiel de connaissance des populations rencontrées par les équipes de Médecins du Monde permettant de faire le lien entre leurs conditions de vie, leur environnement, leurs droits et leurs problèmes de santé, d'observer les discriminations dans l'accès aux soins, les dysfonctionnements des dispositifs, mais aussi les expériences positives. Il contribue à enrichir la connaissance des populations vulnérables en France, par ailleurs largement ignorées par les statistiques officielles françaises de santé publique : les données portent sur un nombre important de personnes sans domicile fixe ou vivant avec un statut administratif précaire sur le territoire. En 2015, Médecins du Monde a effectué 38 483 consultations médicales et plus de 34 000 consultations ou entretiens sociaux au sein de ses centres d'accueil de soins et d'orientation (Caso) et réalisé plus de 20 000 contacts dans le cadre de ses actions mobiles envers les plus exclus (personnes vivant à la rue, en squat ou en bidonvilles, personnes se prostituant, usagers de drogues, migrants en transit).

Chastand, A. (2020). "Attentes vis-a-vis du médecin généraliste et expériences de soins premiers des personnes en situation de prostitution dans l’agglomération bordelaise". Bordeaux, Université de Bordeaux.

https://dumas.ccsd.cnrs.fr/dumas-02933460v1/file/Med_generale_2020_Chastand%20pdf.pdf

Introduction : si les besoins de santé des personnes en situation de prostitution (PSP) et leurs difficultés d’accès aux soins sont à ce jour bien documentés, il n’existe pas, à notre connaissance, de travaux explorant précisément leurs représentations et ressentis sur le recours aux soins primaires. L’objectif principal de notre étude était d’identifier les attentes spécifiques des PSP dans une consultation de médecine générale. Méthode : une étude qualitative a été menée à Bordeaux de septembre 2018 à mai 2019 auprès de PSP recrutées par le biais d’associations de terrain. Les entretiens semi-dirigés ont été enregistrés, retranscrits, codés par deux chercheurs et analysés selon la théorie ancrée. Résultats : 17 femmes ont été interviewées, âgées de 19 à 60 ans et de six nationalités différentes. Le médecin généraliste (MG) était reconnu comme un interlocuteur privilégié de la santé du fait de son accessibilité, de la continuité du suivi apporté et de la pluralité de ses compétences. Le parcours de soin était conditionné par la situation sociale des personnes justifiant le recours à de multiples structures de santé. Les patientes attendaient du praticien une prise en charge globale médico-psycho-sociale ainsi que des compétences relationnelles et communicationnelles : bienveillance, non-jugement, empathie, écoute attentive. La verbalisation de l’activité en consultation était difficile, du fait d’une crainte de stigmatisation et d’une pratique considérée comme honteuse par les femmes. Elle était cependant reconnue comme nécessaire à une prise en charge adaptée aux situations de vulnérabilité médico-psycho-sociale rencontrées. Le MG détenait un rôle dans l’ouverture du dialogue et la libération de la parole des patientes. Conclusion : la promotion d’une « approche-centrée vers le patient » est favorable à une prise en charge satisfaisante et à l’accès aux soins des PSP. Le MG doit s’inscrire dans une démarche de réflexion et de remise en question constante de sa pratique, permettant de déconstruire les représentations sociales et de lutter contre la stigmatisation. Favoriser une ouverture du dialogue en consultation est bénéfique à un accompagnement adapté et à la délivrance de messages de prévention, vers une amélioration de leur santé globale.

Colmet-Daâge, T. (2023). "Les déterminants au suivi gynécologique chez les femmes se prostituant. Étude qualitative par théorisation ancrée basée sur le discours des femmes se prostituant et du personnel médico-social à Toulouse." Université de la Réunion. Thèse de médecine

https://dumas.ccsd.cnrs.fr/dumas-04452834

Contexte : La santé gynécologique des femmes se prostituant est précaire. Pourtant leur accès aux soins, notamment préventifs, est faible. Cette étude avait pour but d’évaluer les déterminants de l’accès aux soins gynécologiques chez les femmes se prostituant dans la ville de Toulouse. Méthode : Étude qualitative par théorisation ancrée réalisée à Toulouse. Nous avons interrogé les femmes se prostituant (population 1) et le personnel médico-social (population 2) à travers le CeGIDD (Centre Gratuit d’information, de Dépistage et de Diagnostic) et les associations Amicale du Nid, Grisélidis et Ikambere.

Deblaise, G. (2022). "Facteurs limitant et renforcant le recours à la PrEP des femmes en situation de prostitution de l’arc alpin". HAL (Le Centre pour la Communication Scientifique Directe), Centre National de la Recherche Scientifique.

La prophylaxie pré-exposition (PrEP) est un outil à part entière dans la prévention de l’infection par le VIH depuis quelques années. Ce mode de prévention initialement porté par la communauté HSH reste limité chez les femmes en situation de prostitution en France : en effet, sur près de 24 000 personnes prenant régulièrement la PrEP en 2020 en France, seulement 300 étaient des femmes (toutes indications confondues). Face à ce constat, nous avons mené un travail pour comprendre comment des personnes en situation de prostitution se positionnent face à ce mode de prévention, et quels seraient les facteurs limitants et favorisants l’accès à la PrEP. Il s'agit d'une étude exploratoire qualitative qui a reposé sur la réalisation d’entretiens semi-directifs auprès de seize femmes en situation de prostitution entre septembre 2020 et octobre 2021. Les profils de ces personnes reflètent ceux qui sont présents dans les données de la littérature. Nos entretiens nous ont permis de mettre en lumière une tendance entre des facteurs de fragilité d’ordre administrative et financière d’une part et la prise de risque lors de la pratique prostitutionnelle d’autre part. Parmi les facteurs limitants l’accès à la PrEP, la peur du jugement porté par les acteurs du monde médical et le manque de visibilité de la PrEP auprès des femmes en situation de prostitution limitent particulièrement l’accès à ce moyen de prévention. Parmi les principaux facteurs favorisant, on identifie des sentiments forts de protection de son corps et de ses proches ainsi qu’un moyen de diminuer la crainte de l’infection par le VIH. Ces entretiens permettent d’identifier des éléments permettant d’améliorer l’accès à la PrEP chez les femmes en situation de prostitution ; ils résident dans l’adaptation de la communication aux différentes populations cibles, et leurs inclusions dans des actions de santé communautaires, et aussi par le mode d’administration de la PrEP dont la forme retard injectable faciliterait l’entrée dans une démarche d’un traitement par PrEP. A ce titre une étude évaluant la faisabilité et l’amélioration de l’accès à la PrEP par Cabotégravir se justifie.

Di Ciaccio, M., et al. (2024). "When awareness is not a barrier to PrEP uptake among men who have sex with men who are eligible for PrEP in France." AIDS Care-Psychological and Socio-Medical Aspects Of AIDS/HIV 36(3): 390-399.

Despite PrEP being available and free of charge in France, a gap remains between the estimated number of men who have sex with men (MSM) with high-risk exposure to HIV and the number of MSM PrEP users. The objective of this study is to identify factors associated with non-intention to use PrEP among PrEP-eligible and PrEP-aware MSM in France, "non-intenders". European MSM Internet Survey (EMIS)-2017 was a cross-sectional survey conducted among MSM concerning their HIV prevention needs. Logistic regression models were used to identify factors associated with "non-intenders". Compared to PrEP users, factors associated with non-intention to use PrEP were: age (aOR[95%CI] = 3.80[2.21;6.53]); not being vaccinated against hepatitis B (2.20[1.45;3.34]); self-efficacy (1.84[1.29;2.60]); lower knowledge about on-demand PrEP (11.48[7.37;17.87]) and daily PrEP (2.58[1.27;5.25]); not having a PrEP discussion at a hospital (12.39[8.90;17.27]) or at a community service/drop-in (4.93[3.48;6.97]); living in a department with few PrEP access points (1.70[1.10;2.63]).On-demand PrEP may meet the prevention needs of "non-intenders" who have lower HIV risk perception. Increasing communication from health providers and community health workers to all MSM is needed.

Douai, C., et al. (2013). "Observatoire de l'accès aux soins de la mission France de Médecins du Monde : rapport 2012", Paris : Médecins du Monde Mission France - Observatoire de l'Accès aux Soins.

A l'occasion du 17 octobre, Journée internationale du refus de la misère, Médecins du Monde publie son rapport annuel sur l'accès aux soins des plus démunis en France. En 2012, en France, les conséquences de la crise économique sur la santé et l'accès aux soins sont prégnantes. Les inégalités sociales de santé s'accentuent chez les plus démunis. À cela s'ajoutent des réponses publiques souvent plus sécuritaires que sociales, notamment envers les migrants, les personnes se prostituant et les usagers de drogues. Ces personnes accèdent de plus en plus difficilement au système de soins, avec pour conséquence une détérioration de leur état de santé.

Invs (2013). "Etude sur l'état de santé, l'accès aux soins et l'accès aux droits des personnes en situation de prostitution rencontrées dans des structures sociales et médicales." St Maurice , Invs

Les études françaises sur la santé des personnes en situation de prostitution sont rares et remontent pour la plupart au milieu des années 1980 et à l'émergence du sida. Cette étude fait suite à une demande de la Direction générale de la santé (DGS) d'actualiser les connaissances sur la santé des personnes prostituées. Ses objectifs, au travers d'une population rencontrée dans des structures sociales, étaient de collecter des informations sur l'état de santé, l'accès aux soins et aux droits des personnes en situation de prostitution, de recueillir des données de santé observées au cours d'une consultation médicale pour les confronter aux données de santé déclarées, et enfin de comparer l'ensemble des données recueillies à celles existant en population générale. Compte tenu des structures sollicitées, cette étude n'est pas représentative de l'ensemble de la population des personnes en situation de prostitution en France.

Jackson, K. J. (2025). "Perceived Access to HIV Prevention Services Amidst the COVID-19 Pandemic Among Men Who Have Sex with Men (MSM) and MSM Sex Workers in France, Russia, and Türkiye." BMJ Public Health 54(2): 827-839.

This study examined the association between self-identification as a sex worker (SW) and perceived access to pharmacologic and non-pharmacologic HIV prevention methods among MSM in France, Russia, and Türkiye amidst the COVID-19 pandemic. Globally, 17,250 MSM recruited through a geosocial networking smartphone application completed the COVID-19 disparities survey, which was administered between October and November 2020. Approximately 38% of survey respondents were identified as living in France (n = 1269), Russia (n = 3882), and Türkiye (n = 3141) at the time of survey completion. Given the diverse sociodemographic factors and attitudes toward both MSM behavior and commercial sex work in these countries, we conducted a secondary analysis of survey data exploring the relationship between SW status and perceived access to pharmacologic and non-pharmacologic HIV prevention methods during the COVID-19 pandemic. Among respondents in Russia and France, MSM SW status was associated with a reduction in perceived access to condoms/lubricants (p = .001 in Russia, p < .001 in France). MSM SW in France were less likely to report never using PrEP as compared to non-SW peers (RR = 0.40, p = .005). Our findings highlight the disparities in access to HIV prevention for MSM SW living in these three countries during the COVID-19 pandemic. Based on our findings, COVID-19 may have exacerbated pre-existing inequities in HIV prevention among populations experiencing intersecting stigmas.

Jego, M., et al. (2025). "Navigating healthcare barriers: a cross-sectional study using respondent-driven sampling to assess migrant women sex workers' access to primary care in France."   BMJ Public Health 3(1): e002234.

INTRODUCTION: Migrant women sex workers (MWSWs) are affected by higher morbidity rates, reflecting the complex health risks associated with sex work and migration which they face. This study aimed to assess MWSWs' use of primary care services in France, as well as the factors associated with having a family doctor. METHODS: This cross-sectional observational study of 135 cisgender and transgender MWSWs is part of the larger Favoriser l'Accès à la Santé Sexuelle des Travailleuses du Sexe project, which aims to improve global knowledge of and access to sexual healthcare among this population. MWSWs aged 18 years and older were enrolled over 1 year between 2022 and 2023. The primary outcome was the percentage of MWSWs who reported having a family doctor. A best model analysis and a regression model were used to examine associations between having a family doctor and MWSWs' health and social characteristics. RESULTS: Only 33% of participants reported having a family doctor. Among these, 24% had disclosed they were sex workers to the latter. In general, MWSWs had poor access to preventive healthcare (33% had been HIV tested in the previous year, 33% had used contraception and 19% reported lifetime cervical cancer screening). In contrast, most participants (63.5%) perceived they were in good health. In the multivariate analysis, having a family doctor was not significantly associated with better health outcomes or with the quality of healthcare. CONCLUSIONS: The majority of MWSWs did not have a family doctor; this fact compounds existing health vulnerabilities faced by this marginalised population. Improved targeted interventions are needed to increase healthcare access and quality for MWSWs. These interventions should include strategies to enhance communication with healthcare providers about this population's specific needs.

Monteil, N. (2020). "Promouvoir la santé des personnes en situation de prostitution": Diplôme Master 2 Santé Publique

https://dumas.ccsd.cnrs.fr/dumas-03173750

Le paysage prostitutionnel a connu ces dernières années de fortes modifications avec notamment le développement d’une prostitution moins visible et moins accessibles aux actions de réduction des risques et de promotion de la santé. La précarité, la stigmatisation, une forte exposition aux violences sont autant de facteurs venant aggraver les inégalités en termes d’accès aux droits et aux soins. Cette étude qualitative a permis par le biais d’entretiens mais également d’une observation au sein de l’association La Case (Bordeaux) de recueillir les besoins des personnes qui se prostituent dans la rue et via internet et de mettre en avant les difficultés rencontrées par les professionnels dans leurs missions. Elle démontre de l’existence de nombreux freins concernant l’accès aux droits et aux soins creusant potentiellement les inégalités sociales de santé. Le travail réalisé a permis de faire émerger des préconisations visant à promouvoir la santé des personnes qui se prostituent dans une approche globale qui tient compte des réalités de terrain des professionnels, des données de la littérature mais aussi des propositions des personnes prostituées elles-mêmes. Elles reposent notamment sur le développement de l’empowerment, un meilleur accès à l’information, la formation des professionnels et l’implication de tous les acteurs (professionnels de santé, partenaires locaux, élus).

Mosnier, E., et al. (2024). "Enhancing sexual health and empowerment among migrant women sex workers: a community health worker-led intervention in Marseille, France." Front Public Health 12: 1359363.

INTRODUCTION: Given the high infection rate of sexually transmitted infections (STI) among migrant women sex workers (WSWs), it is necessary to understand how to improve prevention, information and care for this vulnerable population. Community health workers (CHWs), by linking community to health services, are positioned to improve health outcomes in migrant communities. This article aims to describe a pilot innovative intervention performed by CHWs to improve sexual health in migrant WSWs. METHODS: This one-year intervention study used a respondent-driven sampling (RDS) to recruit a representative cohort of migrant WSWs in Marseille, France. Four CHWs were recruited from different communities and participated in all stages of the research. They performed individual and group interventions of prevention, support in care and empowerment. Data on participant characteristics, type of intervention and adherence to the intervention were reported via questionnaires given to participants. Simultaneously, semi-structured interviews and informal interviews of migrant WSW, CHWs and care providers were carried out. RESULTS: A total of 132 migrant WSWs were included in the cohort. Very few of them knew about PrEP (12%) or already used HIV post-exposure treatment (9%). Migrant WSWs were often victims of rape or racism, 15 and 21%, respectively. In two-thirds of cases the level of health literacy was low. Participants suffered from a combination of vulnerability factors: difficulties with access to social rights, food or housing. Only 13% reported having benefited from medical follow-up or assistance by an NGO in the 3 months prior to the program. By 3 months, more than one third of the participants had been tested for HIV (35%) and 63% knew about PrEP. A total retention rate of 70% was reported in the cohort after 6 months. CONCLUSION: CHWs enabled to improve care access for migrant WSWs by improving the collaboration between care and social actors at a local level. Through these "bring-back-to" interventions for this hard-to-reach population, CHWs enabled an optimization of the care pathway. Our results also highlight the importance of a population-based approach for individual and group support of empowerment interventions in order to strengthen their capacity for action.

Mosnier, E., et al. (2023). "Effectiveness of a Community Empowerment Intervention to Improve Access to Pre-exposure Prophylaxis in Migrant Women Sex Workers: Protocol for a Mixed Methods Implementation Study." JMIR Res Protoc 12: e42844.

BACKGROUND: The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection. However, at-risk women very rarely use PrEP in France-this represents a critical issue among migrant women sex workers (MWSWs). Previous studies on PrEP use among women sex workers or migrants focused on individual or social determinants of motivation. However, operational studies in real-word settings using a holistic population approach to maximize PrEP adherence among MWSWs are lacking. OBJECTIVE: FASSETS (ie, "Favoriser l'Accès à la Santé Sexuelle des Travailleuses du Sexe"; English: "facilitate the access to Sexual Health in women sex workers") is a participative, multilevel, mixed methods study aiming to improve global knowledge of and access to sexual health care and PrEP among MWSWs through targeted empowerment strategies. METHODS: This study comprises several phases: (1) phase 1: an initial qualitative study combining semistructured interviews, informal interviews, and participative observations will be performed among MWSWs, local community nongovernmental organizations, and institutions providing sexual reproductive health services to identify the determinants of PrEP access among MWSWs and for respondent-driven sampling (RDS); (2) phase 2: the size of the hidden MWSW population is estimated in Marseille through capture-recapture (the RDS survey will serve as "recapture"); (3) phase 3: a longitudinal cohort will be formed through RDS to represent the MWSW population with a goal of 150 inclusions-this cohort will be followed up for 12 months, and sequential questionnaires exploring medical history; knowledge of sexual health, HIV, and sexually transmitted infections; migration route; and current living conditions will be administered at inclusion (month 0) and months 3, 6, and 12 to measure the following interventional phase's outcomes; and (4) phase 4: an interventional study with community empowerment actions about sexual health and PrEP will be conducted with community health workers; standardized questionnaires and semistructured interviews, observations, and focus groups will highlight MWSWs' experiences with empowerment resources, concerns about sexual health, and especially PrEP use or uptake, and we will evaluate whether and how community-adapted empowerment actions conducted by community health workers are effective in increasing access to sexual health, prevention and screening of sexually transmitted infections, and PrEP knowledge and access among MWSWs. RESULTS: Recruitment commenced on March 1, 2022. We estimate the follow-up period to end on September 30, 2023. CONCLUSIONS: This multiphase study will provide robust evidence about the magnitude of the MWSW population in Marseille (the second largest town in France) and their current conditions of living, access to and knowledge of sexual health, and PrEP access. Using a mixed methods analysis, we will investigate whether individual and collective community health empowerment approaches can facilitate access to PrEP and its initiation, use, and adherence in this vulnerable population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42844.

Mouvement du Nid (2025). "Etude ASPIRE (Accès aux soins, Santé et Prostitution) : une recherche participative sur les réalités et les besoins des personnes prostituées et survivantes ". Clichy , Mouvement du Nid

Cette étude qualitative menée par l'association du Mouvement du Nid, en partenariat avec l’Inserm et la Sorbonne Université, dresse un état des lieux actualisé et global de la santé et de l’accès aux soins des personnes connaissant ou ayant connu la prostitution. Au-delà de produire des données scientifiques encore trop rares sur le sujet, elle vient démontrer qu’il est tout aussi nécessaire de sortir de la prostitution pour retrouver la santé, que d’être bien soignée pour pouvoir sortir de la prostitution, confirmant par-là les observations de terrain de l’association.

Odendall, M. (2016). "Les obstacles à l'accès aux soins des femmes se prostituant dans la rue : étude qualitative en région parisienne en 2015". Paris : Université Paris 7 Denis Diderot.       

Pignedoli, C., et al. (2024). "Mobiliser des savoirs communautaires dans la médiation en santé : le cas de la PrEP parmi les femmes trans, migrantes, travailleuses du sexe, séronégatives." Revue française des affaires sociales N° 243(3): 133-153.

https://shs.cairn.info/revue-francaise-des-affaires-sociales-2024-3-page-133

Cet article est issu de l’enquête opérationnelle « Personnes trans et PrEP » ayant une approche communautaire de la recherche. Dans un premier temps, il documente les parcours et les réalités de vie matérielles des femmes trans, migrantes, travailleuses du sexe (TDS), séronégatives au cours de la crise sanitaire liée au Covid-19, ainsi que les obstacles qu’elles rencontrent dans l’accès à la prophylaxie pré-exposition (PrEP) – un traitement préventif du VIH – et aux soins. Dans un deuxième temps, il documente les savoirs communautaires mobilisés dans la médiation en santé de deux associations pour accompagner ce groupe vers la PrEP. L’article repose sur l’interprétation descriptive d’entretiens avec des femmes trans, migrantes, TDS sous PrEP (n = 8) et des représentant·es d’associations (n = 9). Le cumul de mobilités induites par des facteurs structurels entrave l’accès au soin des femmes trans, migrantes, TDS. Les conditions de vie de cette communauté se sont davantage détériorées pendant la pandémie. Les profils communautaires et les savoirs expérientiels mobilisés dans la médiation en santé permettent le développement de stratégies d’« aller-vers » et de rétention dans les soins adaptés.

Poncet-Bernard, V., et al. (2021). "L’influence des dynamiques communautaires dans l’amélioration de l’accès aux soins : réalisation et analyse d’un diagnostic exploratoire communautaire des besoins en santé des travailleur.se.s du sexe rennai.se.s" ; Rennes , EHESP. Mémoire EHESP – Promotion santté et prévention

Ce mémoire porte sur l’analyse du diagnostic communautaire exploratoire réalisé cette année concernant les besoins en santé des travailleur.se.s du sexe (TDS) rennais.es. Nourri par les réflexions liées à la facilitation communautaire et positionnant les TDS comme de réel.le.s partenaires, cette étude permet de valoriser l’action communautaire comme stratégie efficace auprès de publics considérés comme « vulnérables ». La relation de confiance créée avec l’association communautaire Les Pétrolettes pérennise l’accompagnement et la prise en compte de cette population dans l’élaboration d’interventions et projets à leurs égards. Celle-ci ne parle pas « en leur nom » mais visibilise leurs paroles, avançant leurs capacités d’agir et de s’exprimer en tant qu’individus. Bien qu’implanté dans un contexte spécifique, ce diagnostic atteste de la félicité d’une approche pragmatique vis-à-vis de l’implication des TDS en tant qu’acteur.trice.s dans leurs parcours de soin. (R.A.)

Queruel, N. et Bertin, B. (2017). "Espaces Femmes à Paris 18e : Se poser, à l'abri de la violence de la rue [Interview]." Santé en action (la)(440): 45-46.

[BDSP. Notice produite par SANTE-PUBLIQUE-FRANCE DAIR0x9B. Diffusion soumise à autorisation]. L'espace femmes à Paris dans le 18e arrondissement, est un lieu d'accueil pour les femmes usagères de drogues et les femmes prostituées. L'accès est anonyme, gratuit, le lieu est chaleureux et sécurisant : les femmes peuvent s'y poser sans formuler une demande précise. Éducateurs, infirmier, médecin, socio-esthéticienne, podologue assurent un accompagnement pluridisciplinaire de ces femmes vivant dans une grande marginalité.

Queruel, N. et Bressieux, C. (2016). "Un accompagnement social, de santé et administratif aux personnes prostituées [Interview]." Santé en action (la)(438): 48-49.

[BDSP. Notice produite par SANTE-PUBLIQUE-FRANCE GtFH9R0x. Diffusion soumise à autorisation]. L'équipe des Lucioles va à la rencontre des personnes prostituées et leur propose un accompagnement personnalisé dans leurs démarches administratives, sociales et de santé.

Shahbazkia, R. (2023). "Recours aux soins de santé primaires chez les travailleuses du sexe migrantes à Marseille". Aix-Marseille Université - École de médecine: 28.

https://dumas.ccsd.cnrs.fr/dumas-04147075

Contextualisation : le travail sexuel et le fait d’être en situation de migration constituent des facteurs favorisant la morbi-mortalité. L’accès aux soins est limité pour les travailleuses du sexe migrantes. Le manque de connaissance concernant leur suivi médical limite l’adaptation du système de santé à cette population. Objectif : décrire le recours aux soins des travailleuses du sexe, migrantes à Marseille en recherchant leur taux de suivi par un médecin référent (critère de jugement principal) et les caractéristiques de leur parcours de soins. Secondairement rechercher les facteurs associés à la déclaration d’un médecin référent. Méthodes : étude quantitative descriptive transversale, ancillaire à FASSETS. Un recrutement par respondent driving sampling a permis l’accès à cette population dite « cachée ». Les données sociodémographiques, cliniques, de parcours de soins et les facteurs associés à la déclaration d’un médecin référent ont été analysés de façon descriptive et univariée. Résultats : cent-trente-quatre femmes ont étaient incluses (âge moyen = 36 ans). La majorité des femmes étaient née au Nigeria ou en Algérie. Quarante-cinq femmes (33.6%) déclaraient avoir un médecin référent. Parmi elles, 24.4% (n=11) déclaraient l’avoir informé de son activité de travailleuse du sexe. Trente-cinq d’entre elles (26.1%) ne bénéficiaient d’aucune couverture sociale. Trente-quatre femmes (25.4%) déclaraient avoir au moins une pathologie chronique et 12 femmes (9%) déclaraient avoir contracté une IST sur l’année. Seulement 30.6% (n=41) des femmes avait bénéficié d’un dépistage du VIH sur l’année. Les facteurs statistiquement associés à la déclaration d’un médecin référent étaient: âge, pays de naissance, posséder une couverture sociale, année d’arrivée sur le territoire, présence d’une pathologie chronique, dépistage du cancer du col utérin à jour et mauvaise auto-évaluation de santé. Discussion : il s’agit de la plus grande cohorte nationale de travailleuses du sexe migrantes. La monocentricité de l’étude et la non-inclusion des mineures peut limiter la généralisation des résultats. Les travailleuses du sexe migrantes n’ont en majorité pas de suivi médical. Lorsqu’il existe, celui-ci est insatisfaisant. Pour améliorer l’accès au soin et sa qualité, il faudrait analyser les difficultés d’abord de la santé sexuelle en médecine générale et discuter la création de projets de santé communautaire permettant un plus grand empowerment des populations vulnérables.

A l’étranger

Abel, G. (2014). "Sex workers' utilisation of health services in a decriminalised environment." N Z Med J 127(1390): 30-37.

BACKGROUND: In 2003 the Prostitution Reform Act (PRA) was passed in New Zealand which decriminalised all activities associated with sex work. AIM: To explore sex workers' utilisation of health services in New Zealand following decriminalisation of sex work and disclosure of their occupation to health professionals. METHOD: A cross-sectional survey was carried out with 772 sex workers and in-depth interviews were carried out with 58 sex workers in New Zealand. RESULTS: Most sex workers have regular sexual health check-ups and most access their general practitioner (GP) for both general health needs (91.8%) and sexual health needs (41.3%). A quarter of the participants accessed a local sexual health centre for their sexual health needs and just over 15% accessed New Zealand Prostitutes' Collective's (NZPC's) Sexual Health Clinic. Little change was found in disclosure of occupation to health professionals following decriminalisation. Sex workers remain concerned about disclosing their occupation because of perceived stigma attached to their occupation. CONCLUSION: Most sex workers have regular sexual health check-ups and most access their GP for this service. However, because of on-going perceptions of stigmatisation many do not report their occupation to their GP which may mean that check-ups may not be comprehensive. For this reason, sexual health check-ups performed at NZPC may be preferable to check-ups elsewhere because disclosure of occupation is not an issue.

Ali, H., et al. (2013). "Increasing access by priority populations to Australian sexual health clinics." Sex Transm Dis 40(10): 819-821.

Data from a network of 35 Australian sexual health clinics, in geographically diverse locations, showed that the number and proportion of patients from priority populations (ie, young people, men who have sex with men, indigenous people, and female sex workers) increased significantly between 2004 and 2011.

Avallone, F. et Hickson, F. (2024). "Sexual Health Needs Among Men Who Engage in Transactional Sex with Men in the UK." Arch Sex Behav 53(6): 2397-2404.

Men who engage in transactional sex with men (MTSM) are a high-risk population for HIV and other sexually transmitted infections. Epidemiological data have so far included them in the broad category of men who have sex with men (MSM), while research on transactional sex typically focused on female sex workers. The internet has substantially changed sex work practices and earlier findings concerning the sexual health needs of MTSM may no longer be applicable. We analyzed quantitative data from MSM based in the UK (n = 11629) taking part in the European MSM Internet Survey (EMIS-2017). Compared to non-MTSM, MTSM (n = 230; 2%) were younger, more likely to self-identify as an ethnic minority, be single, have lower education levels, struggle financially, and-controlling for age-more likely to be living with diagnosed HIV. Commonly unmet needs among all MSM were a lack of confidence in accessing HIV post-exposure prophylaxis, uncertainty about HIV status, and ignorance of where to access hepatitis vaccinations. Compared with other MSM, MTSM were notably less satisfied with the safety of their sexual practices, less confident in their ability to maintain sexual boundaries, and more likely to engage in risk because of absent precautionary resources. Given their greater opportunity for sexual risk, as well as fewer resources for negotiating safety, our findings suggest that services should prioritize MTSM in HIV prevention and sexual health promotion, including assertiveness and social skills training, in addition to knowledge-based education.

Benoit, C., et al. (2016). "Unmet health care needs among sex workers in five census metropolitan areas of Canada." Can J Public Health 107(3): e266-e271.

OBJECTIVES: This paper examines unmet health care needs in one of Canada's most hard-to-reach populations, adult sex workers, and investigates whether their reasons for not accessing health care are different from those of other Canadians. METHODS: Data gathered in 2012-2013 from sex workers aged 19 and over (n = 209) in five Canadian census metropolitan areas (CMAs) were analyzed to estimate the perceived health, health care access and level of unmet health care needs of sex workers, and their principal reasons for not accessing health care. These data were collected using questions identical to those of the Canadian Community Health Survey (CCHS) Cycle 2.1, 2003. The results were compared with those of residents aged 19 and over in the same CMAs who had participated in the CCHS. RESULTS: Sex workers reported notably worse perceived mental health, poorer social determinants of health (with the exception of income) and nearly triple the prevalence of unmet health care needs (40.4% vs. 14.9%). Those with the greatest unmet health care needs in both groups were younger, unmarried or single and in poorer health, and reported lower income and a weaker sense of community belonging. Even without these within-group risk factors, sex workers were more likely to report unmet health care needs compared with CCHS respondents. Sex workers were also more likely to identify "didn't get around to it", "too busy", "cost", "transportation problems" and "dislike doctors/afraid" as reasons for eschewing care. CONCLUSION: Equity policies that reduce cost and transportation barriers may go some way in helping sex workers access needed health care. Qualitative research is needed to better understand the realities of sex workers' personal and work lives, including the degree of freedom they have in accessing health care when they need it, but also their experiences when they do manage to engage with the health care system.

Blanc, A., et al. (2023). "Travailleuses* du sexe aux urgences: quand le tabou entrave les soins [Sex workers: when taboos get in the way of care in the emergency department]." Revue medicale suisse 19(837): 1466-1469.

En Suisse, le travail du sexe est légal sous certaines conditions depuis 1942 et le nombre de travailleuses du sexe (TS) en 2011 était estimé entre 14 000 et 20 000 sur l’entier du territoire, dont 96 % de migrantes. Ces personnes sont exposées à de nombreuses vulnérabilités, de par leur métier mais également en raison de lacunes structurelles et institutionnelles. La complexité de leur prise en charge a mené au fil du temps à la création de structures et d’unités spécialisées, qui sont souvent méconnues des professionnels de la santé. L’objectif de cet article est de mettre en lumière ces lieux et de proposer aux soignants des conseils adaptés afin d’améliorer la prise en charge des TS au service d’urgences.

Busza, J., et al. (2023). "HIV prevention in individuals engaged in sex work." Curr Opin Infect Dis 36(1): 1-8.

PURPOSE OF REVIEW: People who sell sex remain at disproportionate risk of acquiring HIV and should be prioritized for evidence-based HIV prevention programmes delivered at sufficient scale and intensity for effectiveness. Although new biomedical tools are becoming available, many basic lessons learned early in the HIV pandemic remain salient today and need renewed attention. RECENT FINDINGS: New preexposure prophylaxis formulations, distribution systems, and delivery mechanisms are being successfully trialled and implemented, adding to well established prevention tools such as male and female condoms and lubricants. The importance of social support networks and community ownership of programmes has been consistently reaffirmed. Serious challenges remain in optimizing HIV prevention for sex workers, including providing services at the scale and intensity necessary for population level impact, addressing culturally sensitive issues of gender identity and sexual orientation, and protecting adolescents and young people who may sell sex. Pervasive social stigma, often reinforced by criminalization and police harassment, further constrain sex workers' access to available services and prevention tools. SUMMARY: Meaningful community engagement and addressing the multiple social determinants of vulnerability at individual, community, and structural levels remain at the core of preventing HIV among people involved in selling sex.

Castañeda, H. (2013). "Structural vulnerability and access to medical care among migrant street-based male sex workers in Germany." Soc Sci Med 84: 94-101.

This article discusses health concerns of migrant street-based male sex workers (SMSW) in Germany, a population that remains underexplored by health and social scientists. It is based on five months of ethnographic research in 2011/2012, including 46 semi-structured interviews with physicians, social workers, health department staff, and SMSW from Romania and Bulgaria. This is supplemented with annual reports by organizations providing assistance to this population in eight cities. The article contributes, first, an analysis of the increase in migrant SMSW as a response to economic opportunities (freedom of movement across European Union borders) and constraints (transitional measures restricting access to the labor market). It seeks to move beyond the myopic association between sex work and HIV to contextualize health risks as resultant of macro-level processes associated with migration. Second, the article contributes a summary of primary health concerns for this population. Especially troubling is their lack of access to regular medical services, reflecting a socio-legal position that often resembles that of unauthorized migrants rather than European Union citizens.

Darling, K. E., et al. (2013). "Suboptimal access to primary healthcare among street-based sex workers in southwest Switzerland." Postgrad Med J 89(1053): 371-375.

OBJECTIVES: Street-based sex workers (SSWs) in Lausanne, Switzerland, are poorly characterised. We set out to quantify potential vulnerability factors in this population and to examine SSW healthcare use and unmet healthcare requirements. METHODS: We conducted a cross-sectional questionnaire-based survey among SSWs working in Lausanne's red light district between 1 February and 31 July 2010, examining SSW socio-demographic characteristics and factors related to their healthcare. RESULTS: We interviewed 50 SSWs (76% of those approached). A fifth conducted their interviews in French, the official language in Lausanne. 48 participants (96%) were migrants, of whom 33/48 (69%) held no residence permit. 22/50 (44%) had been educated beyond obligatory schooling. 28/50 (56%) had no health insurance. 18/50 (36%) had been victims of physical violence. While 36/50 (72%) had seen a doctor during the preceding 12 months, only 15/50 (30%) were aware of a free clinic for individuals without health insurance. Those unaware of free services consulted emergency departments or doctors outside Switzerland. Gynaecology, primary healthcare and dental services were most often listed as needed. Two individuals (of 50, 4%) disclosed positive HIV status; of the others, 24/48 (50%) had never had an HIV test. CONCLUSIONS: This vulnerable population comprises SSWs who, whether through mobility, insufficient education or language barriers, are unaware of services they are entitled to. With half the participants reporting no HIV testing, there is a need to enhance awareness of available facilities as well as to increase provision and uptake of HIV testing.

Davis, W. W., et al. (2016). "[Local health study : Outreach medical services for female sex workers in Bochum]." Women Health 67(12): 989-995.

BACKGROUND: Inadequate access to prevention and medical treatment for female sex workers (SW) represents a challenge for the German health system. Accessibility and care for SW in Bochum (Germany) through a cooperation between the Interdisciplinary Immunology Outpatient Clinic, Center for Sexual Health and Medicine of St. Josef's Hospital, the Bochum health department and the Madonna e.V. was the focus of this work. PATIENTS AND METHODS: Medical outreach services were provided for the diagnosis of sexually transmitted infections (STI) in SW in brothels in Bochum between August 2013 and January 2014. After clarification and verbal consent from the SW, free HIV, syphilis, chlamydia, gonorrhea and trichomoniasis tests were offered and carried out using pseudonyms for the SW. RESULTS: A total of 112 SW were reached (up to 55.4 % within the framework of the STI Outreach Study). Of the SW, 94.6 % had an immigrant background. The majority (61.3 %) of SW were between 20 und 29 years old. Only 19.0 % of the collective had health insurance. The following STIs were diagnosed: 12.5 % chlamydia, 6.2 % syphilis, 3.6 % gonorrhea, 3.6 % trichomoniasis, and 0.9 % HIV. These results were compared with results from STI studies in SW in Germany. Treatment was performed in accordance with the standards of the German STI Society. CONCLUSION: The offer improved the accessibility and the utilization of medical services by SW in Bochum. A further improvement of services is urgently needed.

Esler, D., et al. (2008). "Sexual health care for sex workers." Aust Fam Physician 37(7): 590-592.

BACKGROUND: The Australian STI Prevention Framework identifies sex workers as a priority group. The Hunter New England Sexual Health Unit, based at the Royal Newcastle Hospital (New South Wales) provides free sexual health care to sex industry workers. OBJECTIVE: To assess current service delivery and barriers to accessing sexual health care by registered brothel based sex industry workers in the Hunter New England area. METHOD: An on site survey of 36 sex industry workers was conducted. RESULTS: Seventy-four percent of participants sought sexual health advice from a general practitioner compared to 37% from the sexual health unit. Seventy-seven percent of participants reported having their sexual health screening carried out according to guidelines. The most frequently stated reason for not using the sexual health unit was the inconvenience of clinic opening times. DISCUSSION: This study highlights the important role that GPs play in providing sexual health care to sex industry workers. It provides the impetus for future research, education and strategies to improve health service delivery to this important group of patients.

Faissner, M., et al. (2024). "Healthcare for sex workers—access, barriers, and needs." Ethik in der Medizin 36(2): 151-168.

https://doi.org/10.1007/s00481-024-00815-8

Stigma has a significant impact on the health of different societal groups and contributes to inequalities in healthcare. Sex work is associated with significant social stigma, which has detrimental effects on sex workers’ access to healthcare. This exploratory study gives first insights into the perspectives of sex workers and counselors in Germany on sex workers’ access, needs, and barriers with respect to healthcare. We focused on an established network of services for sex workers in Bochum.

Flath, N. L. et Brantley, M. R. (2019). "Patterns of primary healthcare use among female exotic dancers in Baltimore, Maryland."  59(3): 334-346.

Female exotic dancers (FEDs) are often exposed to violence-, sex- and drug-related occupational harms and are precluded from employer-based health insurance. We examined access to primary health-care resources, correlates of use, and service needs among a sample of new FEDs (N = 117) working in 22 exotic dance clubs (EDCs) in Baltimore, MD. Self-administered surveys were completed between May and October 2014. Health care measures were aggregated and described, and correlates of use were evaluated using Fisher Exact and Poisson regression with robust variance, adjusting for race/ethnicity. The majority of dancers reported having health insurance (80%), a primary care provider (PCP) (68%), and having visited a PCP (74%). Among dancers with insurance, all were covered by Medicaid. Multivariable regression models demonstrated that having a regular PCP was associated with recent PCP use (adjusted prevalence ratio 1.5; 95% confidence interval: 1.1, 2.1). Despite a high level of health-care coverage and recent visits to PCP, dancers frequently sought services at the emergency department and reported needs for medical care, including mental health support services and drug treatment. Findings highlight that basic access to primary health care is available and used but may not be fully meeting dancers' complex needs.

Folch, C., et al. (2013). "Female sex workers and access to social and health services in Catalonia: Influence of region of origin and place of work." AIDS Care 25(8): 1033-1038.

The objectives of the study were to describe the use of social and health services (SHS) of female sex workers (FSW) in Catalonia according to place of work and region of origin, and explore the barriers these women encountered when accessing these services. Quantitative and qualitative methods were combined. A questionnaire-based survey (n = 400) was conducted from October 2009 to January 2010 and complemented by focus group discussions technique (n = 23). More than 60% of FSW had used health services (HS) in the last 6 months (no differences by context of work and region of origin). Nevertheless, there were differences in the characteristics of health resources used. Although all women in clubs contracted the private HS provided by the club itself, they were those who least benefited from social services (SS), in particular Eastern-Europe women (24.6% in the last 6 months). The stigma and discrimination that FSW women suffer were one of the main barriers to access SHS. Women from Eastern Europe who worked in clubs were the most isolated and vulnerable women. Access to the public health system must continue to be provided for all FSW, assuring confidentiality and diminishing the burden associated with discrimination which they generally feel.

Gloor, E., et al. (2011). "[Sex workers: limited access to healthcare]." Rev Med Suisse 7(301): 1429-1433.

Sex workers constitute a heterogeneous group possessing a combination of vulnerability factors such as geographical instability, forced migration, substance addiction and lack of legal residence permit. Access to healthcare for sex workers depends on the laws governing the sex market and on migration policies in force in the host country. In this article, we review different European health strategies established for sex workers, and present preliminary results of a pilot study conducted among 50 sex workers working on the streets in Lausanne. The results are worrying: 56% have no health insurance, 96% are migrants and 66% hold no legal residence permit. These data should motivate public health departments towards improving access to healthcare for this vulnerable population.

Gloor, É., et al. (2022). Chapitre 2.5. Travailleuses du sexe et accès aux soins. In : Vulnérabilités, diversités et équité en santé. Genève, Médecine & Hygiène: 317-326.

https://stm.cairn.info/vulnerabilites-diversites-et-equite-en-sante--9782880495121-page-317

Les travailleuses du sexe constituent un groupe hétérogène qui cumule les facteurs de vulnérabilité, comme l’instabilité géographique, la migration forcée, les addictions et l’absence d’un permis de séjour. Leur accès aux soins dépend notamment des lois régissant le « marché du sexe » et de la politique migratoire du pays d’accueil 1. Dans cet article, nous passons en revue diverses stratégies sanitaires européennes destinées à ce groupe vulnérable et celles mises en place ces dernières années à Lausanne. Nous présentons également les résultats d’une étude pilote réalisée auprès de 50 travailleuses du sexe pratiquant dans les rues de Lausanne en 2011. Les résultats sont préoccupants : 56% des personnes interrogées n’ont pas d’assurance maladie, 96% sont migrantes et 66% sans permis de séjour. Ces résultats devraient sensibiliser les décideurs politiques à soutenir les projets visant à améliorer l’accès aux soins des travailleuses du sexe. La prostitution, activité légale en Suisse 2, reste un domaine peu étudié sur le plan sociodémographique et médical. Des statistiques en termes de nombre de travailleuses du sexe (TS), d’origines, de lieux de vie, de conditions de travail, d’affiliations à une assurance maladie, d’états de santé et de motifs de consultations médicales sont difficiles à obtenir, car nombreuses sont celles qui exercent dans un contexte très marginalisé et dans la clandestinité. Cette problématique sociale rend l’accès aux soins potentiellement difficile. À ces facteurs de vulnérabilité s’ajoute une mobilité géographique importante, avec pour conséquence un parcours dans le système de santé peu documenté…

Goldenberg, S. M., et al. (2024). "Gaps in health coverage for racialized im/migrant sex workers in metro Vancouver: Findings of a community-based cohort study (2014-2021)." Journal of Migration and Health 10.

Background: Sex workers face substantial health inequities related to sexual health and gender-based violence, many of which are amplified for the large proportion of workers who are racialized im/migrants. While criminalization and stigma are known barriers to health care for this population, we know little about health insurance coverage, and in particular how this relates to im/migration experience and racialization. We examined associations between im/migration status, duration, and racialization on gaps in health insurance coverage in a cohort of women sex workers. Methods: Analyses used data from a prospective, community-based cohort of women sex workers in Vancouver, BC (Sept 2014-August 2021). Interviewer-administered questionnaires were by experiential (current/former sex workers) and community-based staff. We developed multivariable logistic regression confounder models with generalized estimating equations (GEE) to examine associations between migration and racialization exposures of interest and health insurance coverage. Results: Of 644 sex workers, 411 (63.8%) reported lacking health insurance coverage for services needed during the 7-year study. In multivariable GEE analysis, precarious im/migration status (adjusted odds ratio (AOR) 2.37, 95% confidence interval (CI) 1.56 - 3.60), recent (AOR 4.22, 95% CI 2.42 - 7.35) and long-term (AOR 2.13, 95% CI 1.54 - 2.96) migration, and being a racialized Asian im/migrant (AOR 3.06, 95% CI 2.14 - 4.39) were associated with recent lack of health insurance coverage. Conclusion: Policy and program reforms are needed to decouple health insurance access from immigration status, remove mandatory waiting periods for health insurance coverage, and ensure that provincial insurance provides sufficient coverage for marginalized women's healthcare needs.

Harris, M. T. H., et al. (2025). "Social-structural barriers to primary care among sex workers: findings from a community-based cohort in Vancouver, Canada (2014-2021)." BMC Health Serv Res 25(1): 134.

BACKGROUND: Due to social-structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers' broader primary healthcare access, we aimed to examine social-structural factors associated with primary care use among sex workers over 7 years. METHODS: Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify social-structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders. RESULTS: Amongst the 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced primary care use (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49-0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51-1.14). CONCLUSIONS: This study characterized primary care use and its social-structural determinants among sex workers over 7 years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care utilization. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.

Isernia, V. (2025). "Pre-exposure prophylaxis (PrEP) uptake and retention in care in a group of transgender women at high risk of HIV: a French cohort of follow-up." J Immigr Minor Health.

INTRODUCTION: Despite high HIV prevalence rates among trans women (TW), few preventive interventions have targeted this population. METHODS: We described sociodemographic and clinical data from a cohort of TW followed up for pre-exposure prophylaxis (PrEP) at the Sexual Health Clinic of Bichat hospital in Paris between 2016 and 2023, via a multidisciplinary community-led PrEP programme.The total number of TW starting PrEP and having ongoing follow-up each year was assessed. We described retention in care at 3, 6 and 12 months and median time of follow-up. Incidence of PrEP discontinuation was calculated using Poisson regression. RESULTS: Between January 2016 and December 2023, 209 TW have been followed up for PrEP at Bichat Hospital, with a median age of 36 years and mostly originating from South America (79.4%, 166/209). Seventy-four per cent of TW (155/209) were sex workers and 53.6% (112/209) had regular health insurance. Most of TW were on daily PrEP (94.3 %, 197/209). The total number of TW followed-up for PrEP per year increased from 17 in 2016 to 129 in 2023. Median time of follow-up was 10.3 months and incidence of PrEP discontinuations was 58.2 (CI 95% 49.51 to 68.57) per 100 persons-year. Retention in care at 6 and 12 months was, respectively, 62% and 38% for users who started PrEP in 2016 and 81% and 31% for those who started in 2022. Seven per cent of TW (13/190) experienced adverse events, leading to PrEP discontinuation in 10/190 cases. Two cases of HIV seroconversion were reported, both in TW who had stopped PrEP for gastrointestinal intolerance. CONCLUSIONS: Our multidisciplinary reach-out community-led PrEP programme has increased PrEP access among our cohort of TW. Rates of retention in such a prevention programme of care remained poor. More interventions are needed to analyse PrEP barriers and improve retention in care for this specific population.

Isernia, V., et al. (2021). "Pre-exposure HIV prophylaxis (PrEP) among transgender women: 3 years of follow-up in a university hospital in Paris."  97(6): 465-466.

OBJECTIVES: The principal outcome was to describe clinical characteristics of a transgender male-to-female (TGW) cohort followed for pre-exposure HIV prophylaxis (PrEP). INTRODUCTION: Few efforts and preventive interventions have targeted transgender population, despite them being at great risk of HIV infection. METHODS: This was a retrospective transgender male-to-female (TGW) cohort followed for PrEP at Bichat Hospital Sexual Health Clinic between February 2016 and January 2019.The principal outcome was to describe clinical characteristics of this TGW population: modalities of PrEP uptake, treatment adherence and tolerance, sanitary system retention, hormonal therapy and STIs. Data about age, ethnicity, language, sex work and sanitary healthcare insurance coverage were also collected. RESULTS: Forty-nine TGW were included, with a median age of 33 years; 43/49 (87.7%) were from South America and 43/49 (87.7%) were sex workers. Forty-four 44/49 TGW (89.7%) had no regular healthcare insurance coverage. Nineteen out of 49 (38.7%) had a history of STI in the last 12 months. Hormone intake was reported in 16/49 (32.60%). PrEP with oral TDF/FTC was prescribed on a daily basis for 45/49 TG (91.8%). Two TGW discontinued PrEP for gastrointestinal intolerance. No case of renal toxicity or HIV seroconversion has been reported. Retention rate was high (71.4%), but average follow-up was 9 months. CONCLUSIONS: Our data showed a very vulnerable population, with a high proportion of migrants, sex workers and with a low healthcare insurance coverage. Retention rate was high (71.4%). Further multi-component interventions are needed to improve global sex health approach, PreP follow-up and sanitary system retention among TGW population.

Jeal, N. et Salisbury, C. (2007). "Health needs and service use of parlour-based prostitutes compared with street-based prostitutes: a cross-sectional survey." Bjog 114(7): 875-881.

OBJECTIVES: To compare the health needs of prostitutes (sex workers) working in massage parlours with that of those working on the streets. DESIGN: Cross-sectional survey. SETTING: Inner city, UK. POPULATION: Women aged 16 years and older selling sex in massage parlours. METHODS: Interviewer-administered questionnaires were undertaken with 71 parlour workers, and results were compared with our previous findings for street sex workers. MAIN OUTCOME MEASURES: Self-reported experiences of health and service use. RESULTS: In comparison with street sex workers, parlour sex workers were less likely to report chronic (43/71 versus 71/71; P < 0.001) and acute (10/71 versus 35/71; P < 0.001) illnesses but more likely to be registered with a GP (67/71 versus 59/71; P = 0.06). They were more likely than street sex workers to have been screened for sexually transmitted infections in the previous year (49/71 versus 33/71; P = 0.011) and more likely to use contraception in addition to condoms (34/71 versus 8/71; P < 0.001). They were less likely to be overdue for cervical screening (5/46 versus 19/48; P = 0.001), and more of those booked for antenatal care in the first trimester attended all follow-up appointments (28/37 versus 14/47; P < 0.001). Fewer parlour sex workers used heroin (4/71 versus 60/71; P < 0.001), crack cocaine (5/71 versus 62/71; P < 0.001) or injected drugs (2/71 versus 41/71 versus; P < 0.001) They reported fewer episodes of intercourse per week (mean 14 versus 22; P < 0.001) with fewer different men (mean 11 versus 19; P < 0.001), less of whom were new (mean 8 versus 13; P < 0.001). CONCLUSIONS: The two groups had very different health experiences, risk-taking behaviour and use of services. To be effective in improving health, different types of service delivered in different settings for different groups are required.

Jeal, N. et Salisbury, C. (2004). "Self-reported experiences of health services among female street-based prostitutes: a cross-sectional survey." Br J Gen Pract 54(504): 515-519.

BACKGROUND: Previous studies show that women working in prostitution do not use routine health services appropriately. Little is known about the nature and frequency of service contacts or barriers to access. This information is needed if use of current services by this group is to improve. AIM: To identify barriers reducing access to health services by street prostitutes, and to identify current patterns of use. DESIGN OF STUDY: Cross-sectional survey. SETTING: Inner-city Bristol. METHOD: Seventy-one female street-based prostitutes were interviewed about their experiences of health services. RESULTS: The women had frequent contacts with healthcare providers. The general practitioner (GP) was the main source of all types of care. Although 83% (59/71) were registered with a GP, 62% (36/59) had not disclosed their work. Only 46% (33/71) had been screened for sexually transmitted infection in the previous year and 24% (17/71) were vaccinated against hepatitis B, a national recommendation for sex workers. Only 38% (25/65) had had cervical smears according to screening guidelines. Opportunistic screening and care was important. While pregnant with their last child, only 30% (14/47) booked in the first trimester and attended all antenatal appointments, with 13% (6/47) receiving no antenatal care until admitted in labour. Appointments, waiting times, and fear of judgement and other patients staring, were considered significant barriers to service use. The model suggested by the women was an integrated service providing basic living needs alongside health care. CONCLUSION: Non-disclosure and poor attendance for follow-up make appropriate care difficult, and may contribute to poor health. Despite frequent service contacts, opportunities for care are being missed.

Kielhold, K., et al. (2025). "Everyday discrimination and barriers to primary care, mental health, and substance use services: Findings from a community-based cohort of sex workers in Vancouver, Canada (2015-2024)." PLOS Glob Public Health 5(6).

We evaluated the association between discrimination and access to primary, mental health, and substance use services among sex workers. Using baseline and semi-annual questionnaire data from a community-based cohort of sex workers in Vancouver, Canada (09/2015-02/2024), we used bivariate and multivariable logistic regression with generalized estimating equations to analyze the relationship between discrimination and access to primary care, mental health, and substance use services. Among 518 participants (2768 observations), the median discrimination score was 19 (IQR:11-25), indicating substantial discrimination. In separate multivariate models, every one-point increase in discrimination was associated with increased odds of experiencing barriers to health services (adjusted odds ratio (AOR):1.03, 95%CI:1.02-1.04), unable to access health services when needed (AOR:1.03, 95%CI:1.01-1.04), unmet need for mental health services (AOR:1.04, 95%CI:1.03-1.06), experiencing barriers to counseling for sexual trauma (AOR:1.04, 95%CI:1.02-1.05), and unmet need for substance use treatment (AOR:1.07, 95%CI:1.04-1.09). Discrimination is highly prevalent and associated with reduced access to primary, mental health, and substance use services among sex workers. There is a need for anti-discrimination efforts, including provider training and sex worker partnerships in primary care, alongside policy reforms.

King, E. J., et al. (2017). "Motivators and barriers to HIV testing among street-based female sex workers in St. Petersburg, Russia." Glob Public Health 12(7): 876-891.

Female sex workers are particularly susceptible to HIV-infection in Russia. However, a dearth of information exists on their utilisation of HIV services. A mixed-methods, cross-sectional study was conducted to examine motivators and barriers to HIV testing among street-based sex workers in St. Petersburg, Russia. The health belief model was the theoretical framework for the study. Twenty-nine sex workers participated in in-depth interviews, and 139 sex workers completed interviewer-administered surveys between February and September 2009. Barriers to getting an HIV test were fear of learning the results, worrying that other people would think they were sick, and the distance needed to travel to obtain services. Motivators for getting tested were protecting others from infection, wanting to know one's status and getting treatment if diagnosed. Logistic regression analysis demonstrated that knowing people living with HIV [aOR = 6.75, 95% CI (1.11, 41.10)] and length of time since start of injection drug use [aOR = 0.30, 95% CI (0.09, 0.97)] were significantly associated with recently getting tested. These results are important to consider when developing public health interventions to help female sex workers in Russia learn their HIV status and get linked to care and treatment services if needed.

Kızıltaş, Ö. et Fidancı, İ. (2025). "Health care experiences of female sex workers: a qualitative study." Fam Pract 42(4) : cmaf048

BACKGROUND: Sex workers face significant barriers to accessing health services, including stigma, economic constraints, and safety concerns. In Turkey, this group is often subjected to discrimination and prejudiced approaches when accessing sexual health services, which reduces the uptake of health services. This study aims to analyze the health care experiences of sex workers in depth. METHODS: The study conducted semi-structured in-depth interviews with 16 women working as sex workers in Adana brothel in July-October 2024, and the data were analyzed through thematic analysis. Participants were selected through purposive sampling to ensure socio-demographic diversity. RESULTS: Four main themes were identified through the analysis: Barriers to Access and Use of Health Services, Health Service Experiences and Satisfaction, Information and Awareness, and Emotional Situations. Participants indicated that they often preferred private health facilities due to difficulties in accessing public health services and long waiting times, but that these preferences were limited by cost. CONCLUSIONS: Improving the quality of public health services and reducing costs may improve public health by encouraging this group to use health services.

Lowe, P., et al. (2019). "Pregnancy prevention and contraceptive preferences of online sex workers in the UK." Eur J Contracept Reprod Health Care 24(6): 444-448.

Objectives: The internet has changed the organisation of sex work. The risk of sexually transmitted infections has frequently been a research focus but less is known about sex workers' use of contraception for pregnancy prevention. The aim of this research was to gain a better understanding of contraceptive preferences and provider interactions of online sex workers. Methods: Data were obtained from a multi-methods study of sex workers in the UK who advertise on the internet and have sexual contact with clients, particularly in the Birmingham and Solihull areas. The study comprised an online survey among 67 participants and eight qualitative interviews. Results: Reported high rates of condom use with clients led to sex workers considering pregnancy prevention to be a personal rather than an occupational issue. Disclosure of sex working to health professionals is often seen as unnecessary and/or undesirable due to concerns about stigma. A clear distinction between contraceptive needs for commercial and non-commercial partners was evident. Conclusion: Service providers need to take account of both personal and commercial needs during contraceptive consultations and avoid making assumptions based on homogeneous understandings of sex work. Encouraging disclosure of sex work to facilitate appropriate discussions may need new approaches to combat privacy and stigma concerns.

Mastrocola, E. L., et al. (2015). "Access to healthcare for long-term conditions in women involved in street-based prostitution: a qualitative study." BMC Fam Pract 16: 118.

BACKGROUND: Women involved in street-based prostitution (SBP) have well-documented health problems specific to their occupation, but access to care for other chronic health problems has not been explored. Primary care is seen as the optimal context to deliver care for people with long-term conditions because it is accessible, efficient, and can tackle inequalities related to socioeconomic deprivation. We aimed to explore the perspectives of women involved in SBP about access to health care for their long-term conditions. METHODS: This was a qualitative study with women accessing a third sector organization in North West England. Semi-structured interviews were conducted with sixteen women involved in SBP and accessing support. Data were analysed using the principles of constant comparison and a framework approach. RESULTS: Women described how they were living with ill health, which they found difficult to manage, and often impacted on their work. Women reported poor access to care and viewed any ensuing consultations in primary care as unsatisfactory. CONCLUSION: This study highlights the unmet health needs of women who work in SBP, not just related to their occupation, but due to their co-morbid long-term conditions. Access to primary care was reported to be problematic and interactions with general practitioners not fulfilling their expectations, which impacted on future consultation behaviour. Understanding the health-seeking behaviours and self-management strategies of women involved in SBP with chronic health problems is essential in the design and commissioning of services and may reduce unscheduled care in this under-served group.

McBride, B., et al. (2019). "Third Parties (Venue Owners, Managers, Security, etc.) and Access to Occupational Health and Safety Among Sex Workers in a Canadian Setting: 2010-2016." Am J Public Health 109(5): 792-798.

OBJECTIVE: To determine the impact of engagement with third parties (i.e., managers, receptionists, or owners of in-call venues; advertisers; security; spotters; and others) on sex workers' occupational health access. METHODS: We drew longitudinal data from An Evaluation of Sex Workers' Health Access, a community-based cohort of more than 900 women sex workers. We used multivariable logistic regression and generalized estimating equations to (1) examine factors correlated with accessing third-party administrative or security services and (2) evaluate the impact of third-party services on access to mobile condom distribution and sex worker and community-led services (2010-2016). Finally, we evaluated changes in accessing third-party services pre-post end-demand criminalization (2010-2017). RESULTS: Im/migrant sex workers (persons with any type of legal status who were born in another country; adjusted odds ratio [AOR] = 2.32; 95% confidence interval [CI] = 1.35, 3.98) had higher odds of accessing third-party services. In confounder models, third-party services were independently correlated with increased access to mobile condom distribution (AOR = 1.84; 95% CI = 1.47, 2.31) and sex worker and community-led services (AOR = 1.61; 95% CI = 1.15, 2.24). End-demand criminalization was linked to a decrease in access to third-party services (AOR = 0.79; 95% CI = 0.63, 0.99). CONCLUSIONS: This research suggests that access to administrative and security services from third parties increases sex workers' occupational health and safety. Policy reforms to ensure sex workers' labor rights, including access to hiring third parties, are recommended.

McBride, B., et al. (2023). "Association between interrupted access to sex work community services during the COVID-19 pandemic and changes in sex workers' occupational conditions: findings from a community-based cohort study in Vancouver, Canada." BMJ Open 13(1): e065956.

OBJECTIVES: Globally, criminalisation has shaped sex workers' structural exclusion from occupational protections, and this exclusion has been exacerbated during the COVID-19 pandemic. While community organisations aim to bridge this gap through providing health and safety resources for sex workers, many were forced to scale back services when Canadian provinces declared a state of emergency at the pandemic onset. As little empirical research has examined the impacts of sex work community services interruptions amid COVID-19, our objectives were to (1) examine the correlates of interrupted access to community services and (2) model the independent association between interrupted access to community services and changes in working conditions (ie, self-reported increases in workplace violence or fear of violence), among sex workers during the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: As part of an ongoing community-based cohort of sex workers in Vancouver, Canada (An Evaluation of Sex Workers Health Access, 2010-present), 183 participants completed COVID-19 questionnaires between April 2020 and April 2021. ANALYSIS: Cross-sectional analysis used bivariate and multivariable logistic regression with explanatory and confounder modelling approaches. RESULTS: 18.6% of participants (n=34) reported interrupted access to community services (closure/reduction in drop-in hours, reduced access to spaces offering sex worker supports and/or reduced access/contact with outreach services). In multivariable analysis, sex workers who had difficulty maintaining social supports during COVID-19 (adjusted OR, AOR 2.29, 95% CI 0.95 to 5.56) and who experienced recent non-fatal overdose (AOR 2.71, 95% CI 0.82 to 8.98) faced marginally increased odds of service interruptions. In multivariable confounder analysis, interrupted access to community services during COVID-19 was independently associated with changes in working conditions (ie, self-reported increases in workplace violence or fear of violence; AOR 4.00, 95% CI 1.01 to 15.90). CONCLUSIONS: Findings highlight concerning implications of community service interruptions for sex workers' labour conditions. Sustainable funding to community organisations is urgently needed to uphold sex workers' occupational safety amid COVID-19 and beyond.

Molloy, E., et al. (2025). ""They look you up and down like you are nothing": A qualitative exploration of sex workers' health needs and interactions with UK healthcare services." Int J Nurs Stud Adv 9: 100392.

BACKGROUND: Sex workers are frequently regarded by health services as a homogenous group whose health needs are related exclusively to the services they provide. Little research has explored sex workers' health needs from their own perspectives. AIM: To understand their healthcare needs from their experiences and perspectives. DESIGN: We undertook a four phase multi-method study to assess the health needs of sex workers in Birmingham, UK. This article reports the findings from qualitative interviews with sex workers (phase three). SETTINGS: This study was conducted in the UK with sex workers living and/or working in Birmingham, UK. PARTICIPANTS: 20 sex workers (10 men, 6 women, 2 trans/non-binary, and 2 not disclosed), were interviewed who were over 18 (21-40yrs): offering paid for sexual services involving in-person interactions. Online only service providers were excluded. Participants were recruited via partner organisations, personal networks, and social media (X). METHODS: We undertook semi-structured interviews which explored healthcare needs and access for sex workers. Interviews were audio-recorded. Audio files were transcribed, and clean transcripts imported into NVivo to support data analysis. Transcripts were thematically analysed and mapped deductively against the adapted Andersen Model of Healthcare Service Utilisation. RESULTS: Themes interpreted from interview analysis related to healthcare need, enabling factors, service provision and barriers to access. A further category "In an Ideal World" was interpreted inductively reflecting gaps in current healthcare service provision and access. Themes included: fear of judgement and stigma; social taboos; feeling unheard and dismissed by services (missed opportunities for engagement); judgmental service provision; and availability of tailored services and appropriately trained staff. CONCLUSIONS: Many sex workers experiences were underpinned by frequent exposure to psychological and physical trauma and violence, either related to lifetime experiences, experiences as a sex worker, and through contact with healthcare or support services. The intersecting marginalised identities of many sex workers were also a feature of their trauma exposure and interactions with healthcare staff. Recommendations include creation of holistic services; training of non-judgemental staff with insight into the complexities of sex work and the intersections of the multiple marginalisations sex workers face; appropriate training for staff in statutory services, e.g., General Practitioner (GP) primary healthcare practices; trained points of contact who can advocate and educate within their services; availability of peer support; integrated service pathways incorporating 'fast track' referral systems between partner organisations.

O'Donnell, P., et al. (2016). "Exploring levers and barriers to accessing primary care for marginalised groups and identifying their priorities for primary care provision: a participatory learning and action research study." Int J Equity Health 15(1).

Background: The involvement of patients and the public in healthcare has grown significantly in recent decades and is documented in health policy documents internationally. Many benefits of involving these groups in primary care planning have been reported. However, these benefits are rarely felt by those considered marginalised in society and they are often excluded from participating in the process of planning primary care. It has been recommended to employ suitable approaches, such as co-operative and participatory initiatives, to enable marginalised groups to highlight their priorities for care. Methods: This Participatory Learning and Action (PLA) research study involved 21 members of various marginalised groups who contributed their views about access to primary care. Using a series of PLA techniques for data generation and co-analysis, we explored barriers and facilitators to primary healthcare access from the perspective of migrants, Irish Travellers, homeless people, drug users, sex workers and people living in deprivation, and identified their priorities for action with regard to primary care provision. Results: Four overarching themes were identified: the home environment, the effects of the 'two-tier' healthcare system on engagement, healthcare encounters, and the complex health needs of many in those groups. The study demonstrates that there are many complicated personal and structural barriers to accessing primary healthcare for marginalised groups. There were shared and differential experiences across the groups. Participants also expressed shared priorities for action in the planning and running of primary care services.Conclusions: Members of marginalised groups have shared priorities for action to improve their access to primary care. If steps are taken to address these, there is scope to impact on more than one marginalised group and to address the existing health inequities.

Pearson, J., et al. (2023). "An Evaluation of Indoor Sex Workers' Sexual Health Access in Metro Vancouver: Applying an Occupational Health & Safety Lens in the Context of Criminalization." Int J Environ Res Public Health20(3):1857

The criminalization of sex work has been consistently shown to undermine workers' Occupational Health and Safety (OHS), including sexual health. Drawing on the 'Guide to OHS in the New Zealand Sex Industry' (the Guide), we assessed barriers to sexual health best practices among indoor sex workers in Metro Vancouver, Canada, in the context of ongoing criminalization. Part of a longstanding community-based study, this analysis drew on 47 qualitative interviews (2017-2018) with indoor sex workers and third parties. Participants' narratives were analyzed drawing on a social determinants of health framework and on the Guide with specific focus on sexual health. Our findings suggest that sex workers and third parties utilize many sexual health strategies, including use of Personal Protective Equipment (PPE) and peer-driven sexual health education. However, participant narratives demonstrate how structural factors such as criminalization, immigration, and stigma limit the accessibility of additional OHS best practices outlined in the Guide and beyond, including access to non-stigmatizing sexual health assessments, and distribution of diverse PPE by third parties. Our current study supports the need for full decriminalization of sex work, including im/migrant sex work, to allow for the uptake of OHS guidelines that support the wellbeing and autonomy of all sex workers.

Potter, L. C., et al. (2022). "Access to healthcare for street sex workers in the UK: perspectives and best practice guidance from a national cross-sectional survey of frontline workers." BMC Health Serv Res 22(1): 178.

BACKGROUND: Street sex workers (SSWs) are a highly marginalised and stigmatised group who carry an extremely high burden of unmet health need. They experience multiple and interdependent health and social problems and extreme health inequality. Despite high levels of chronic physical and mental ill-health, there is little evidence of effective healthcare provision for this group. They are often considered 'hard to reach', but many individuals and organisations have extensive experience of working with this group. METHODS: We conducted a cross-sectional survey of professionals who work with SSWs in the UK on their perspectives on their access to primary care, mental health, sexual health and drug and alcohol services, how well these services met the needs of SSWs and suggestions of best practice. RESULTS: 50 professionals mostly from England, responded. Mainstream general practice and mental health services were found to be largely inaccessible to SSWs. Sexual health, drug and alcohol services and homeless health services better met their needs; this was mostly attributed to flexible services and collaborations with organisations who work closely with SSWs. The main challenges in providing healthcare to SSWs were services being inflexible, under-resourced services and services not being trauma-informed. Best practice in providing healthcare to SSWs includes- seamless partnership working between agencies with case worker support; peer-involvement in service development and engagement, a range of health provision including outreach, presence in community spaces and fast-track access into mainstream services; trauma-informed, gender-sensitive health services in a welcoming environment with flexible, responsive appointment and drop-in systems and consistent clinicians with specialist knowledge of substance misuse, mental health, domestic violence and homelessness. CONCLUSIONS: Access to healthcare for SSWs in the UK is highly variable but largely inadequate with regards to primary care and mental health provision. The examples of positive healthcare provision and partnership working presented here demonstrate the feasibility of accessible healthcare that meets the needs of SSWs. These need to be systematically implemented and evaluated to understand their impact and implications. As we build back from COVID-19 there is an urgent need to make accessible healthcare provision for marginalised groups the norm, not the exception.

Probst, U. (2023). "Health insurance for the good European citizen? Migrant sex workers' quests for health insurance and the moral economy of health care." Social Science & Medicine 319.

European health insurance systems have become increasingly fragmented due to neoliberal health care reforms and the privatization of health care. Attempts to enable transnational access to public health care services throughout the European Union (EU) have contributed to this process by spreading ideas of EU citizens as consumers having to make informed choices about health insurance. However, marginalized populations such as EU migrant sex workers are presented with only limited choices within these systems. This article highlights how these limitations in access to health insurance are not only related to financial precarities, but are also caused by underlying racialized, classist, and sexualized assumptions about citizenship and belonging which influence the legal framework of both national and EU-wide health insurance provision. Based on ethnographic research with migrants from eastern EU countries involved in sex work in Berlin, the article discusses their attempts to gain access to health insurance as a salient example of the moral economy of health insurance provision in a supposedly universal health care system. Following how migrant sex workers from eastern European countries experience and negotiate exclusions from health insurance systems, the article addresses how meanings and interpretations of health insurance change towards an understanding of health insurance not as a right, but as a privilege for those conforming to narrow ideas of European citizenship. This indicates that current restructurings of health insurance systems are not only characterized by increasing privatization. Equally, the (re-)emergence of links between access to health insurance and restrictive ideas of belonging and citizenship rights are undermining aspirations for transna-tionally available universal health care.

Ramos, S. D., et al. (2024). "Dimensional Reduction in Barriers and Facilitators to Pre-exposure Prophylaxis (PrEP) Uptake Willingness for Full-Service Sex Workers." Arch Sex Behav 53(2): 799-810.

Full-Service Sex Workers (FSSWs) face heightened risk of acquiring HIV, yet exhibit relatively low adoption of pre-exposure prophylaxis (PrEP)-an antiviral that substantially reduces HIV acquisition risk. Little work examines barriers and facilitators to PrEP uptake willingness among FSSWs. This study aimed to identify the distinct components of barriers and facilitators to PrEP uptake willingness for FSSWs. Here, we subjected 19 PrEP barriers and facilitators identified in the literature to a principal component analysis (PCA) among a sample of 83 FSSWs. Preliminary statistics supported factorability of data. PCA revealed three distinct components of barriers and facilitators that explained 62.80% of the total variance in survey responses. We labeled these components Behavioral and Social Concerns (alpha = 0.93), Access and Affordability (alpha = 0.67), and Biologically Based Health Concerns (alpha = 0.79). This study shows promise for future clinical and research utility of these factors and provides a basis for future psychometric studies of barriers and facilitators to PrEP uptake willingness among FSSWs.

Socías, M. E., et al. (2016). "Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada." PLoS One 11(5): e0155828.

BACKGROUND: Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers' experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC. METHODS: Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers' Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013). RESULTS: In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10-1.94), workplace- (AOR = 1.31, 95% CI 1.05-1.63), and community-level violence (AOR = 1.41, 95% CI 1.04-1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03-1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34-2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59-7.57) emerged as independent correlates of institutional barriers to health services. DISCUSSION: Despite Canada's UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers' health and human rights.

Schmidt, D., et al. (2023). "[Evaluating the introduction of HIV pre-exposure prophylaxis as a benefit of statutory health insurance (EvE-PrEP) : Highly effective protection against HIV without an increase in sexually transmitted infections]." Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 66(9): 1008-1018.

BACKGROUND: We investigated the impact of HIV pre-exposure prophylaxis (PrEP) as a new service of the statutory health insurance (SHI) on the incidence of HIV and other sexually transmitted infections (STIs) in Germany. In addition, PrEP needs and access barriers were analyzed. METHODS: The following data were evaluated as part of the evaluation project: HIV and syphilis notification data and extended surveillance by the Robert Koch Institute (RKI), pharmacy prescription data, SHI routine data, PrEP use in HIV-specialty care centers, Checkpoint, the BRAHMS and PrApp studies, as well as a community board. RESULTS: The majority of PrEP users were male (98-99%), primarily aged between 25-45 years, and predominantly of German nationality or origin (67-82%). The majority were men who have sex with men (99%). With regard to HIV infections, PrEP proved to be highly effective. There were only isolated cases of HIV infections (HIV incidence rate 0.08/100 person years); in most cases the suspected reason was low adherence. The incidences of chlamydia, gonorrhea, and syphilis did not increase but remained almost the same or even decreased. A need for information on PrEP for people in trans*/non-binary communities, sex workers, migrants, and drug users emerged. Needs-based services for target groups at increased risk of HIV are necessary. DISCUSSION: PrEP proved to be a very effective HIV prevention method. The partly feared indirect negative influences on STI rates were not confirmed in this study. Due to the temporal overlap with the containment measures during the COVID-19 pandemic, a longer observation period would be desirable for a conclusive assessment.

Socías, M. E., et al. (2015). "Gaps in the hepatitis C continuum of care among sex workers in Vancouver, British Columbia: Implications for voluntary hepatitis C virus testing, treatment and care." Can J Gastroenterol Hepatol 29(8): 411-416.

BACKGROUND: Hepatitis C virus (HCV) eradication leads to reduced morbidity, mortality and transmission. Despite the disproportionate burden of HCV among sex workers, data regarding the HCV care continuum in this population remain negligible. METHODS: Using baseline data from an ongoing cohort of women sex workers in Vancouver (An Evaluation of Sex Workers' Health Access, January 2010 to August 2013), the authors assessed HCV prevalence and engagement in the HCV care continuum within the past year. Multivariable logistic regression analyses were used to evaluate associations with recent (ie, in the past year) HCV testing. RESULTS: Among 705 sex workers, 302 (42.8%) were HCV seropositive. Of these, 22.5% were previously unaware of their HCV status, 41.7% had accessed HCV-related care, 13.9% were offered treatment and only 1.0% received treatment. Among 552 HCV-seronegative sex workers, only one-half (52.9%) reported a recent HCV test. In multivariable analysis, women who self-identified as a sexual⁄gender minority (adjusted OR [aOR] 1.89 [95% CI 1.11 to 3.24]), resided in the inner city drug use epicentre (aOR 3.19 [95%CI 1.78 to 5.73]) and used injection (aOR 2.00 [95% CI 1.19 to 3.34]) or noninjection drugs (aOR 1.95 [95% CI 1.00 to 3.78]) had increased odds of undergoing a recent HCV test, while immigrant participants (aOR 0.24 [95% CI 0.12 to 0.48]) had decreased odds. CONCLUSIONS: Despite a high burden of HCV among sex workers, large gaps in the HCV care continuum remain. Particularly concerning are the low access to HCV testing, with one-fifth of women living with HCV being previously unaware of their status, and the exceptionally low prevalence of HCV treatment. There is a critical need for further research to better understand and address barriers to engage in the HCV continuum for sex workers.

Sou J, Goldenberg SM, Duff P, Nguyen P, Shoveller J, Shannon K. Recent im/migration to

Canada linked to unmet health needs among sex workers in Vancouver, Canada : Findings of a

longitudinal study. Health Care for Women International. 2017 May 4;38(5):492–506.

Steele, S., et al. (2020). "Self-reported access to health care, communicable diseases, violence and perception of legal status among online transgender identifying sex workers in the UK." Public Health 186: 12-16.

OBJECTIVES: Transgender-identifying sex workers (TGISWs) are among the most vulnerable groups but are rarely the focus of health research. Here we evaluated perceived barriers to healthcare access, risky sexual behaviours and exposure to violence in the United Kingdom (UK), based on a survey of all workers on BirchPlace, the main transgender sex commerce website in the UK. STUDY DESIGN: The study design used in the study is an opt-in text-message 12-item questionnaire. METHODS: Telephone contacts were harvested from BirchPlace's website (n = 592 unique and active numbers). The questionnaire was distributed with Qualtrics software, resulting in 53 responses. RESULTS: Our survey revealed significant reported barriers to healthcare access, exposure to risky sexual behaviours and to physical violence. Many transgender sex workers reportedly did not receive a sexual screening, and 28% engaged in condomless penetrative sex within the preceding six months, and 68% engaged in condomless oral sex. 17% responded that they felt unable to access health care they believed medically necessary. Half of the participants suggested their quality of life would be improved by law reform. CONCLUSIONS: TGISWs report experiencing a high level of risky sexual behaviour, physical violence and inadequate healthcare access. Despite a National Health System, additional outreach may be needed to ensure access to services by this population.

Stopgate, L. et Squires, K. (2024). "Sex Workers in Canada Face Unequal Access to Healthcare: A Systems Thinking Approach." BMJ Sex Reprod Health 15: 21501319241233173.

OBJECTIVES: Despite Canada's universal health system, sex workers across the country face an alarmingly high number of barriers when they seek to healthcare services. This has resulted in unmet healthcare needs and substantially poorer health outcomes than the general Canadian population. The objective of this study was to use a systems thinking approach to gain an in-depth understanding of the barriers sex workers face and how access could be improved. METHODS: The analysis was conducted using a systems thinking methodology, which incorporates systems tools and inquiry processes. The methodology comprised 2 domains of inquiry: (1) Problem Landscape, (2) Solutions Landscape. Systems tools and methods, such as causal loop diagrams, iceberg diagram, and systems mapping, investigated the problem landscape for understanding the interconnected nature of the issue, alongside review of both published and gray literature. An environmental scan explored the current solutions landscape. These methods connected through systemic inquiry processes, including ongoing review and application of diverse perspectives, boundary judgments, interrelationships; enabled gaps and levers of change to be determined. RESULTS: The main barriers sex workers face are stigma, criminalization, accessibility, and cost of healthcare. The stigma of sex work stems from otherization, paternalism, and moralistic, faith-based beliefs. The barriers unique to sex work are stigma and criminalization; both of which surface as avoidance, dislike, and/or fear of medical professionals. Five gaps each with a lever of change to improve access were identified: (1) Stigma - Collectivization and external collaboration, (2) Criminal status of sex work - Decriminalization, (3) Lack of adequate education - Improved healthcare professional training and anti-discriminatory health policies, (4) Lack of support - Increased community-based healthcare services, (5) Cost of healthcare - Universal coverage of "secondary" healthcare components. CONCLUSION: Through reducing the stigma surrounding sex work, making changes that improve the healthcare services that sex workers receive, and collaboration between involved parties, sex workers can be prevented from falling through the cracks of the Canadian healthcare system; lessening the health inequities sex workers face and improving their health outcomes.

Schwartz, S., et al. (2021). Integrated Interventions to Address Sex Workers’ Needs and Realities: Academic and Community Insights on Incorporating Structural, Behavioural, and Biomedical Approaches. Sex Work, Health, and Human Rights: Global Inequities, Challenges, and Opportunities for Action. Goldenberg, S. M., Morgan Thomas, R., Forbes, A. etBaral, S. Cham (CH), Springer

Copyright 2021, The Author(s). 231-253.

Sex workers experience multi-factorial threats to their physical and mental health. Stigma, human rights violations and occupational exposures to violence, STIs, HIV, and unintended pregnancy create complex health inequities that may not be effectively addressed through programmes or services that focus on a single disease or issue. Meeting cisgender female, male, and transgender sex workers’ unmet needs and realities effectively requires more nuanced, multi-faceted public health approaches. Using a community-informed perspective, this chapter reviews layered multi-component and multi-level interventions that address a combination of structural, behavioural, and biomedical approaches. This chapter addresses (1) what are integrated interventions and why they are important; (2) what types of integrated interventions have been tested and what evidence is available on how integrated interventions have affected health outcomes; (3) what challenges and considerations are important when evaluating integrated interventions. Key findings include the dominance of biomedical and behavioural research among sex workers, which have produced mixed results at achieving impact. There is a need for further incorporation and evaluation of structural intervention components, particularly those identified as highest priority among sex workers, as well as the need for more opportunities for leadership from the sex work community in setting and implementing the research agenda.

Taylor, A. K., et al. (2016). "How can general practice respond to the needs of street-based prostitutes?" Br J Gen Pract 66(647): 323-324.

Thng, C., et al. (2018). "Private sex workers' engagement with sexual health services: an online survey." Sex Health 15(1): 93-95.

This study examined where private sex workers (PSW) present for sexual health services, disclosure, services received, and their satisfaction with care. An online anonymous survey was conducted via SurveyMonkey (surveymonkey.com). Among the 53 participants, 42% attended a sexual health clinic, 24% attended a general practitioner (GP) and 34% attended both. Participants attending GPs were less likely to be offered a throat swab and opportunities for cervical screening, contraception and vaccination were often missed in both service models. Participants attending GPs were less likely to disclose sex work and were less satisfied. Better awareness of the sexual health needs of PSWs is important in GP services.

[1] HAS (2016). État de santé des personnes en situation de prostitution et des travailleurs du sexe et identification des facteurs de vulnérabilité sanitaire – Rapport. St Denis, HAS

[2] Plus d’informations sur le site de l’Irdes :  https://www.irdes.fr/recherche/enquetes/tessa-travail-du-sexe-prostitution-sante-soins-et-assurance/actualites.html