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Abstract
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Methods Published and unpublished studies were identified through electronic databases (PsychINFO, CINHAL Plus, MEDLINE, EMBASE, The Cochrane Library and Open Grey), hand searching and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.
- counseling
- health services accessibility
- sex education
- sexual Health
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Key messages
There is a gap in the evidence around the effectiveness of psychosocial interventions aiming to improve sex worker well-being.
Weak evidence exists to support the benefits of ecological momentary assessment in reducing anxiety and depression and improving opportunities for behaviour change.
Research on sex working communities focuses on female street-based sex workers and underrepresents the experiences of male sex workers.
Participatory methodologies are recommended to ensure that future research is grounded in the actual rather than perceived needs of sex working communities.
Introduction
Work on the well-being of sex workers1 has traditionally either focused on the ways in which legal and human rights issues affect sex worker vulnerability,2 or on access to sexual health screening opportunities, in attempts to reduce the acquisition and transmission of sexually transmitted infections (STIs).3
These criminal justice or public health approaches present a limited narrative of sex work as something that is criminal or virologically dangerous. This is further compounded by a focus from sexual health services on biomedical interventions such as condom use,4 HIV pre- and post-exposure prophylaxis (PrEP/PEP)5 and hepatitis B vaccinations6 to support the perceived health needs of sex workers.
The stigma,7 labour and complex routes within sex work place unique demands on the coping resources of sex workers8 highlighting additional well-being needs. Previous studies based on street-based female sex workers evidences some of these psychosocial issues, which include substance misuse, mental health problems, violence, and homelessness.9
This systematic review aims to gather and marshal evidence on the range and effectiveness of psychosocial interventions aimed at improving the well-being of sex workers within resource-rich countries with the aim of producing recommendations to inform policy and practice within the UK.
Methods
Search strategy
PsychINFO, CINHAL Plus, MEDLINE, EMBASE, Open Grey and The Cochrane Library databases were searched throughout January 2020 for peer-reviewed articles published in English between January 2000 and January 2020. Truncated keywords and relevant medical subject headings (MeSH) related to the study’s PICO: ‘sex workers’ (Population), ‘psychosocial interventions’ (Intervention), ‘well-being' (Outcome) were used and linked using Boolean operators (online supplemental appendix 1). The reference list of included articles was also searched in addition to contacting experts in the field and sex worker organisations to further identify any additional eligible articles.10
Supplemental material
Study selection process
The titles of all articles identified from the search were screened by one reviewer (KT). Two reviewers screened the abstracts of the remaining articles (KT and DM). Articles were included if they evaluated a psychosocial intervention using either validated well-being measures or qualitative methodologies, included sex workers or people engaging in exchange or transactional sex,11 and were conducted in high-resource countries (online supplemental appendix 2). Discrepancies were resolved through further discussion with a third reviewer (LS). A protocol for this review was peer reviewed and is registered with the International Prospective Register of Systematic Reviews (PROSPERO) CRD42020204592.
Data extraction
Extracted data inclusive of sample characteristics, intervention type, study methods, outcome measures and findings were extracted by two reviewers (KT and DM) using a standardised form developed by the review team (online supplemental appendix 3).
Quality assessment
A quality assessment was carried out by two reviewers (KT and DM) using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Data12 (online supplemental appendix 4) and the National Institute for Health and Care Excellence (NICE) Quality Appraisal Checklist13 for qualitative data (online supplemental appendix 5). A third reviewer (LS) reviewed any discrepancies.
Analysis
The heterogeneity of the intervention’s aims, study design, outcome measures and sample populations precluded a meta-analysis of their results. A narrative synthesis across qualitative and quantitative data is presented by intervention type. Scientific quality is used to frame the validity of study effect findings, common methodological flaws, risk of bias, and how well studies were conceptualised.
Results
A total of 19 202 articles were identified from the literature search (figure 1). Seventy articles included studies on psychosocial interventions aimed at improving sex worker well-being. Ten articles were selected after full-text review. Reasons for exclusion are documented using a PRISMA flow 14diagram (figure 1). An overview of study characteristics and interventions for qualitative, quantitative and mixed-method studies are presented (table 1).
Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2009 flow diagram.
Summary of study characteristics, data extraction table and quality appraisal outcomes
Study characteristics
Studies from all resource-rich countries were eligible for inclusion but only studies from America (n=6),15–19 followed by Canada (n=2)20 21 and the UK (n=2)1 22 were identified. Five studies exclusively focused on street-based sex workers.1 16 19 21 22 Three studies included sex workers from a variety of contexts including exotic dancing, erotic massage and escorting,17 18 20 while two studies investigated participants engaging in transactional sex.15 23
Intervention characteristics
Interventions included ecologic momentary assessment (EMA) (n=2),15 23 drug treatment services (n=2),1 22 exiting and diversion programmes (n=2),17 18 trauma-informed interventions (n=2),19 21 peer health initiatives (n=1)20 and case management programmes (CMPs) (n=1).16
Evaluation design
Well-being outcomes were measured in quantitative studies by assessing quality of life (QoL), anxiety, depression and post-traumatic stress disorder (PTSD) using validated measures. One study used the Christo Inventory,22 a widely used clinical tool validated as a QoL measure in people who use drugs. Two studies measured depression using either the Patient Health Questionnaire (PHQ-9)15 or the Center for Epidemiological Studies-Depression (CES-D) Scale.19 Anxiety was measured in one study using the Brief Symptom Inventory-Anxiety (BSI-A).15 One study measured PTSD symptom severity using the PTSD checklist.19 All quantitative studies used pre- and post-intervention measures.15 19 22 The timeframe between measures ranged between 4 weeks15 23 and 1 year.22
Semi-structured interviews, observations, journal entries and field notes were used across qualitative studies1 16–21 23 to evaluate the effectiveness of psychosocial interventions.
Summary of findings
Ecologic momentary assessment
EMAs study people’s thoughts and behaviour in their daily lives by repeatedly collecting questionnaire data in their normal environment, at or close to the time they carry out that behaviour. This is achieved through regular self-report diary entries covering key information around risks logged by mobile phone.
In a quantitative study investigating the benefits of EMA through smartphone-enabled diary entries every 12 hours and weekly face-to-face interviews, levels of self-esteem increased from 4.08 points from baseline to exit (p<0.001) over a period of 4 weeks among a sample of 24 women engaging in transactional sex. While mean scores for anxiety and depression decreased from baseline, they were not statistically significant. Women who initiated sex work as minors reported decreased depression between baseline and exit (4.1 points, p=0.05). Anxiety also decreased in women who drank less than four alcoholic drinks per day (1.9 points, p=0.03) and those who used marijuana daily (3.7 points, p=0.05).15
Statistical analysis through the use of t-tests failed to stratify which element of the intervention, EMA or weekly interviews, had the greatest effect on the otherwise combined outcome measures reported. The short study time documented for participating in EMA impacts on the ability to assess sustainability of intervention success outside of the documented 4 weeks. The small sample size of this study further limits the power of the findings to detect differences across wider populations of sex workers.
In a separate study, qualitative evaluations of women participating in transactional sex who engaged in the same intervention experienced a heightened awareness of their emotions and behaviour, resulting in either actual or intended changes in behaviour, including decreased engagement in sex work, sobriety, procurement of condoms, and addressing negative behavioural triggers.23 While the exploratory nature of the study, absence of theoretical framework and small sample (n=25) limits the generalisability of the findings, EMA shows some utility in its ability to facilitate behaviour change to further support sex worker well-being.
Exiting programmes
Exiting programmes address the causes and consequences of sex work to encourage industry exit. Group counselling was experienced as being helpful to women participating in qualitative evaluations of a Prostitution Diversion Programme (PDP), specifically in its utility to facilitate conversations around addiction, abuse, trauma, mental health and relationships.18 These were considered beneficial to both participants and stakeholders who were able to learn directly from lived experiences to further inform and develop group sessions.
Programmes that offered financial assistance to women who were in the early stages of exiting sex work (between 3 months and 1 year) were positively evaluated in a qualitative review of a faith-based exiting programme developed to support sustained exit from the sex industry. Peer support was encouraged by women participating in sex worker support services. Engaging with peers promoted a sense of community belonging and cohesion in addition to presenting opportunities for reinvesting help and support to other sex working women.17
The lack of quantitative-based research inclusive of validated measures to assess intervention success contributes to the weak evidence base for diversion and exiting programmes. Available evidence is grounded in selection bias due to the fact that programme enrolment is largely offered as an alternative to jail time or dependent on a prerequisite to have already exited from sex work.
Drug support
Prescribed maintenance therapy (PMT) in the form of a regulated and controlled prescription for heroin to support drug addiction, along with psychosocial support for female street sex workers from a specialist general practice setting in the UK, reported significant improvements in QoL between pre- and post-test measures recorded 1 year apart (12.05 at entry to 8.97 after 1 year, p<0.001).22
The use of paired t-tests to look for changes in pre- and post-test scores fails to distinguish between the separate effects of PMT and psychosocial interventions. Poor reporting fails to provide a definition as to what psychosocial interventions were offered and how these were accounted for in response to confounding factors. Despite being free from attrition bias, these findings are vulnerable to bias, given that the setting was based in a general practitioner (GP) practice, where over-reporting of healthy behaviour is likely and reporting success could also be perceived by participants as a requisite for securing ongoing prescriptions.
Qualitative evaluations of female street sex workers’ experiences of drug treatment services (n=24) highlight the importance of providing opportunities for sex working women to openly discuss their drug use free from the unwanted attention of male service users. Across the interview data, participants described how feeling unable to discuss their sex work in drug treatment groups undermined their engagement in treatment processes. Non-disclosure meant that they could not discuss unresolved issues around trauma which emerged or increased when reducing their drug use.1
Recommendations were made for sex worker-only services to be delivered by female staff. The provision of one-to-one counselling was felt to provide the opportunities for people to explore personal issues in more depth, which was not possible within group settings. However, these claims lack transferability to male or transgendered sex workers given that the findings reflect the voices and experiences of women.24
Trauma-informed interventions
The development of a safety card, developed in consultation with sex workers, providing harm reduction, safety information and support for accessing violence-related services for sex workers attending an outreach needle exchange service, reported an increase in safety behaviour scores (51.2 to 58.1, p<0.0001) and use of support programmes responding to intimate partner violence (10.5% to 28.9%, p<0.01) between baseline and follow-up (10–12 weeks).19
While no changes were observed at follow-up from high baseline levels of PTSD (mean=51.4) or depression (mean=19.2), avoidance of condom negotiation (2.0 to 1.4, p=0.04) and the average frequency of sex with clients while under the influence of drugs or alcohol (mean=4.4 to 4.0, p=0.04) decreased. The generalisability of these findings is restricted due to rates of data attrition (39/60) and the population being limited to street-based female sex workers already engaging in relevant risk reduction interventions.
Within qualitative evaluations, new knowledge of support organisations included on the safety card prompted and enabled women to offer peer support to friends and colleagues. An enhanced confidence was experienced by women through open discussions, enabled through use of the card, around topics rarely discussed including coercive barriers to condom use and safety
The Persons at Risk Programme (PAR), a harm reduction service which aimed to improve access to healthcare and essential services for street-level sex workers through outreach work undertaken by a GP and police officer, was qualitatively evaluated in a second trauma-informed intervention study.21
The PAR was valued by sex workers for the streamlined and focused nature of care provision in overcoming barriers to services otherwise avoided due to fear of stigma from frontline service staff, including drug abuse, infectious diseases and mental health assistance. However, findings are limited to a sample of women who choose not to access frontline services, who had stopped using drugs and successfully exited sex work.
Peer health initiatives
Findings from qualitative interviews show that peer advocacy in the delivery of a sexually transmitted and blood-borne infection (STBBI) prevention strategy, developed and delivered by sex workers as peer educators,20 led to reduced internalised stigma and increased self-esteem and confidence across participants (n=5). Improved critical consciousness and resource mobilisation were attributed to the inclusion of training materials that promoted diversity within sex working communities and awareness of local support agencies.
Small numbers of participants limits the generalisability of findings in this study and inclusion of broader sex working experiences across wider demographics and geographical contexts. The short duration of the study also restricts our understanding of the long-term sustainability and ownership of peer health initiatives. Future studies incorporating quantitative measures of internalised stigma and self-esteem would help to strengthen the evidence base for peer health interventions. However, the study provides proof of concept that local sex working communities are receptive and willing to participate in peer-led health initiatives.
Case management programmes
In CMPs, a named case manager acts as a fixed point of contact for a patient during the co-ordination of care. One study qualitatively evaluated a community-based CMP for street-walking prostitutes in Florida.16 Across a purposive sample, access to sex worker-specific treatment programmes for substance misuse and support with child custody were identified as important services among sex working women (n=10), while support with engaging in mental services was highlighted by programme staff (n=4) and community professionals (n=9).
The inability to compare outcomes from these services independently of CMP referrals weakens the evidence base for the effectiveness of CMPs. Bias exists in the sample, as the majority of participants had been referred into the service while in jail. Attendance to the programme is likely to be linked to conditions of their parole and therefore not representative of those freely engaging in service provision.
Discussion
Sex workers present with specific health and well-being needs25 beyond the scope of sexual health screening. Despite this, an identifiable gap exists in the current evidence around how to respond to the additional psychosocial needs experienced by sex workers or those engaging in transactional sex.
The results from this review highlight the utility of a range of interventions which aim to improve sex worker well-being including peer health initiatives, EMA (smartphone-based diary intervention), drug support services and trauma-informed interventions. However, the limited information around the study characteristics and small sample sizes reflects low levels of participation beyond street-based female sex workers, limiting the power of studies to detect differences across more diverse and less researched populations including male, transgender and migrant sex workers and those using a range of platforms to engage in wider arenas of sex work.
The implications of these findings are, first, that the field would benefit from broadening definitions of sex work by including wider and more contemporary outlets of sex work such as adult content creators operating on subscription-only platforms. A broader definition of sex work will help to adequately acknowledge and represent the diversification of sex work, helping to challenge perpetuated stereotypes of sex worker identities and their needs.
Poor study design contributed to the weak evidence base for psychosocial interventions aiming to improve sex worker well-being. Across quantitative studies the opportunities for comparison of findings against control groups and an inability to discriminate between intervention effects in statistical analysis impacts our ability to make clear evidence-based recommendations to inform policy and practice within geographical resource-rich countries.
While the evidence for EMA (smartphone-prompted diary approach)15 remains weak and unsubstantiated, participation in regular diary entries enabled by smartphone technology improved self-esteem while encouraging intention for, or actual, behaviour change.23 Further research grounded in behaviour change theory would inform the development of EMA and its ability to identify and support individual psychosocial well-being needs.
The small number of methodologically rigorous studies reflects the challenges of studying this population,26 including the ethical issues such as compensation of sex worker time or researcher standpoint on decriminalisation. Furthermore, barriers to sex worker identification and availability include exacerbation of minority stress, given that sex working practices are perceived to differ from the majority of surrounding society27 and potential breaches in confidentiality which may expose sex workers to public disclosure of highly stigmatised and criminalised identities.28 29
In addressing these issues, some studies included in the review recruited sex workers to patient and public involvement (PPI) roles, to assist in the administration of surveys and questionnaires or facilitation of focus groups.30 Very few authors discussed the pro and cons of this approach, particularly with consideration to any impact on the data collected. Similarly, the use of incentives such as gift cards, travel coupons or money to enable participation remained largely undiscussed.
The use of incentives to recruit research participants remains a controversial issue,31 but was featured in several of the studies included in this review. Sanders32 argues that paying sex workers for gaining access to information about their life experiences is similar to the situation of a client paying the sex worker for gaining access to their body and is highly exploitative. However, Maher33 contends that providing modest renumeration is only fair practice and one that encourages participation. In previous research with socially and economically marginalised communities, uncompensated studies of sex workers often bias the sample towards more privileged and more politically engaged individuals than studies which offer recompense. This is important as much sex work is driven by economic survival.34
Alongside fear of exploitation, community participation in research can be constrained by scepticism that the research will not result in any direct benefit.35 The underuse of participatory methodologies often means that available studies are often conceptualised without relevant engagement with sex working communities or organisations, resulting in the production of research which targets the perceived rather than actual needs of sex workers.
Participatory methodologies along with PPI help to address some of these ethical issues in their ability to develop research that adequately addresses the needs of sex workers while also safeguarding participants from exploitation.35 36 Attempts to engage sex workers in the design of research should not be tokenistic or used to legitimise research, but instead should focus on developing methodologies and equitable partnerships that meet the needs of sex working communities.
The evidence for peer health initiatives20 further highlights the importance of community-based responses that prioritise the engagement of target populations in the development and delivery of support programmes.37 Collective processes, initiated by this engagement, are experienced as helping to create a community voice capable of social and behavioural changes, including improved awareness and access to support services.20 The findings presented in this review provide some proof of concept that peer support is effective in hidden and stigmatised populations38 who do not otherwise engage well with healthcare providers. Peer education may provide the opportunity for sex workers to become authentic educators,39 not only in their community but across public service organisations.
Potential biases of the review process
The scope of this review focused on psychosocial interventions which were evaluated using only validated health and well-being outcome measures, which are considered to be at a reduced risk of bias compared with self-reported measures.40 This may have led to the exclusion of some studies where interventions were less rigorously evaluated, but still experienced as beneficial to overall well-being by participants. Disaggregation of data will have also contributed to the exclusion of studies where sex work is reported within sample characteristics, but not presented separately within research findings.
Conclusions
This systematic review identifies a gap in the evidence base around the effectiveness of psychosocial interventions to support the well-being of sex workers. Available studies are weak in their design and lack generalisability beyond female street-based sex workers. Smartphone-based diarising such as EMA provides some evidence of promoting intentions for behaviour change but, as with other approaches, would benefit from having some focus around how such interventions create change. Finally, peer health initiatives developed in consultation with sex workers offer promise but warrant further investigation.
Additional Educational Resources
The nature and prevalence of prostitution and sex work in England and Wales today. Professor Marianne Hester Prostitution_and_Sex_Work_Report.pdf (publishing.service.gov.uk)
Sex work and mental health: reviewing the occupational risks of sex workers in comparison to other ‘risky’ professions. Professor Teela Sanders Microsoft Word - briefing paper final.docx (le.ac.uk)
Guiding principles for best practice research with sex workers. Samuel Brookfield Barriers to Accessing Sexual Health Services for Transgender and Male Sex Workers: A Systematic Qualitative Meta-summary %7C SpringerLink
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to acknowledge the assistance of Hannah Poore, specialist subject librarian at the University of the West of England Bristol, and Dr Lucy Platt from the London School of Hygiene and Tropical Medicine.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @DrJaneMeyrick
Contributors KT and JM initiated the study and defined the research question. All authors contributed to developing the methodology. KT carried out all literature reviews. KT, DM and LS acted as data reviewers and extractors. JM provided reconciliation in the event of any discrepancies. KT drafted the protocol and the manuscript that was later edited by JM.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The findings and conclusions of this review are those of the authors and do not represent the official position of the University of the West of England Bristol or other institutions with which the authors are affiliated.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.