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Review

Life Intricacies of Sex Workers: An Integrative Review on the Psychiatric Challenges Faced by Sex Workers

by
Mokhwelepa Leshata Winter
* and
Sumbane Gsakani Olivia
School of Medicine, Faculty of Health Science, University of Limpopo, Private Bag X 1106, Sovenga, Polokwane 0727, South Africa
*
Author to whom correspondence should be addressed.
Psychiatry Int. 2024, 5(3), 395-411; https://doi.org/10.3390/psychiatryint5030027
Submission received: 23 April 2024 / Revised: 24 June 2024 / Accepted: 10 July 2024 / Published: 30 July 2024
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Abstract

:
Background: Sex work remains a contentious and marginalized aspect of society, with sex workers facing a myriad of challenges that impact their mental health and well-being. Objective: This review explores, reviews, and examines the psychiatric challenges encountered by sex workers daily and seeks to identify key gaps in the current research and highlight areas of future intervention and support. Methodology: This study followed five stages of the integrative review suggested by Whittmore and Knafl. The identification of the problem, literature search, data evaluation, data extraction, analysis, and presentation of results were the five stages of the integrative review that were carried out. This review examined English-language publications from 2010 to 2023 that discussed the mental health issues that sex workers experienced. Furthermore, this study excluded publications that were published before 2010, articles written in languages other than English, publications whose complete texts could not be retrieved, and works that did not address the mental health problems that sex workers encounter. For their initial search, the writers employed electronic databases like PubMed, Scopus, Psych-Info, Google Scholar, Science Direct, and Medline. The search terms were as follows: ‘sex work’, ‘sex workers’, ‘prostitution’, ‘mental health’, ‘psychiatric challenges’, ‘stigma’, Risk factors’, and ‘barriers’. Results: Following the critical appraisal, out of 150 studies, only 34 studies were chosen for analysis. Using Cresswell’s Tesch method, two themes emerged from this study: (1) mental health challenges faced by sex workers and (2) primary risk factors contributing to their mental health challenges. Conclusions: Moreover, addressing the psychiatric challenges faced by sex workers requires a multifaceted approach that acknowledges the intersectionality of factors influencing sex workers’ mental health outcomes, thus also highlighting the imperative for tailored interventions and support systems to promote their well-being.

1. Introduction

Recently, there has been growing attention given to studies focusing on the psychiatric and mental health issues that sex workers encounter, which are becoming more and more prevalent. Sex workers are particularly susceptible to mental health issues [1]. According to previous research, between 50% and 75% of female former sex workers suffered from a mental illness [1,2,3]. On the other hand, according to the European Parliament, it is estimated that around 40–42 million people worldwide are involved in sex work [3]. Mental health disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD), which alter behavior, thought processes, and interpersonal relationships, can be brought on by poor mental health [4,5,6,7]. Research continuously shows that, compared to the general population, sex workers have greater rates of anxiety and depression [6,7]. This is why female sex workers had a much greater incidence of mental health problems than the general population, as revealed by a rigorous meta-analysis [8]. The combined frequency of suicidal ideation (22.8%), anxiety (21.0%), PTSD (19.7%), sadness (41.8%), and recent suicide attempts (6.3%) has been observed [8]. The prevalence of depression among sex workers has varied throughout the international literature, despite their heightened susceptibility to mental health diseases. Despite this, documented incidence rates have ranged from 4.2% in Bangladesh. On the contrary, when compared to the general population, a study conducted in Australia found no variation in prevalence. Thus, in contrast to studies conducted in Switzerland in Zurich, the lifetime prevalence of anxiety and depression was 34.2% and 36.3%, respectively [9,10]. Lastly, according to a study conducted in Nepal, 84% of female sex workers had depression [11].
International organizations and non-governmental organizations (NGOs) have consistently highlighted the unique challenges faced by sex workers, emphasizing their right to the highest attainable standard of physical and mental health [12]. The Special Rapporteur on the right of everyone to the highest standard of physical and psychological health (SR Health) has reported extensively on the health disparities faced by sex workers, including their heightened vulnerability to mental health issues [12]. Furthermore, the Independent Expert on Protection against Violence and Discrimination based on Sexual Orientation and Gender Identity (IE SOGI) has documented the compounded stigma and discrimination experienced by sex workers, particularly those from marginalized sexual and gender identities [13]. On the other hand, the UN Working Group on Discrimination Against Women and Girls (WGDAWG) has also underscored the systemic inequalities and violence that disproportionately affect female sex workers [14]. These reports provide critical context for understanding the psychiatric challenges faced by sex workers, highlighting the need for comprehensive health and social interventions.
Several research studies have demonstrated that one factor contributing to the mental health issues experienced by sex workers is their subjection to violence [8,9,11]. Firstly, there is a clear correlation between cognitive problems and violence committed by partners of sex workers; those who witness violence from an intimate partner have a higher risk of developing depression than those who do not [13,14]. Secondly, there is a chance that sex workers’ mental health could be jeopardized by violence at work [13]. Nevertheless, sex workers usually operate in dangerous environments, and their bosses regularly treat them brutally, which has a detrimental effect on their mental health [15]. Lastly, it should be noted that client violence is rampant; according to 50% of female sex workers who operate inside (such as in brothels), they have personally witnessed client violence [16]. Thus, about 29% of female sex workers in the Gambia reported having been coerced into having sex with their clients [17]. Without a doubt, partners, employers, and clients frequently commit acts of violence against sex workers, which severely compromises their mental health [16]. Similarly, while selling sex is illegal in most countries, discrimination against them persists, and there is always a risk of violence for female sex workers [18]. Consequently, this seriously jeopardizes their emotional well-being [18].
The pooled prevalence of several mental health issues was revealed in a recent study by Beattie et al., with high estimated levels of PTSD, depression, anxiety, physiological discomfort, mood disorders, and suicidal ideation and attempts [8]. According to data from the baseline quantitative Beksinska et al. study conducted in Nairobi, 14% of participants reported PTSD, and 25% had moderate to severe depression or anxiety [19]. According to a comparable study carried out in Soweto, South Africa, 39% of participants reported PTSD, and 68.7% experienced depression [20]. High levels of anxiety and sadness were also discovered in a previous KwaZulu Natal study among female sex workers who were using support services [21]. Therefore, this study identified potential gaps. Previous studies on the mental health of sex workers lack methodological approaches such as longitudinal research methodology, sample sizes, and limited geographic scope, which hinder the generalizability and depth of the findings. These limitations highlight critical gaps in understanding the full scope of psychiatric challenges faced by sex workers, necessitating a comprehensive review. Additionally, the practical implications of this study are substantial; it aims to inform mental health practitioners and policymakers, leading to better support systems, targeted interventions, and more effective policies tailored to the unique needs of sex workers. Theoretically, this review contributes to the existing body of knowledge by integrating diverse findings and emphasizing the intersectionality of mental health issues, social stigma, and occupational hazards. Thus, this study seeks to provide a detailed analysis of these challenges and offer recommendations for future research practice, thereby addressing a significant gap in the literature. Additionally, there is an urgent need for more comprehensive studies examining the barriers to accessing mental health services, including stigma, affordability, and availability. This study’s relevance is critical as it highlights the unique vulnerabilities and stressors sex workers face, underscoring the need for targeted mental health interventions, informed policymaking, and advocacy efforts to address and mitigate these challenges. Therefore, the goal of this review is to present a thorough understanding of the psychiatric difficulties that sex workers encounter, along with the related circumstances that may contribute to mental illnesses.

2. Literature Review Methodology

A literature review comprises an overview, synopsis, and critical assessment of academic publications concerning a particular subject [22]. It gives a broad overview of current knowledge, making it possible to pinpoint pertinent ideas, approaches, and areas of unmet research needs [23]. The evidence regarding the mental health difficulties experienced by sex workers was compiled using the integrative review method [24,25]. The review was conducted using the five stages of the integrative review technique proposed by Whittemore and Knafl, namely (1) the research question formulation; (2) the literature search; (3) data evaluation; (4) data extraction and analysis; and (5) presentation of results [25].

2.1. Problem Identification

The authors’ initial step involved identifying the problem. Determining the goal and reviewing questions is part of the problem identification stage [24,25]. This integrative review’s primary goal is to compile the most recent findings regarding the mental health issues that sex workers face. The finding that sex workers experience mental health illnesses because of their line of work gives rise to the research problem. This is because prostitution is still illegal in many nations, stigmatized, and leaves prostitutes open to violence. Thus, these variables change regarding their mental health. The following questions guided this review:
(1)
What are the prevalence rates of psychiatric disorders among sex workers, and what are the primary risk factors contributing to their mental health challenges?
(2)
How do experiences of stigma, discrimination, and trauma impact the mental health of sex workers?

2.2. Literature Search

As suitable and pertinent to each chosen database, the search approach incorporated Boolean and keyword truncations. The English language was used as the primary language of reporting for the review. The electronic search was performed on the six databases listed: PubMed, Scopus, Psych-Info, Google Scholar, Science Direct, and Medline. The authors searched in January 2024. The search terms included the following: “mental health” OR “Mental well-being” OR “Mental disorders” *OR* “Mental illness” *OR* “Psychiatric challenges” *OR* “Prostitution” *OR* “Sex work” *OR* “Sex workers” *OR* “Risk factors” *AND* “Barriers.” Notably, the authors attempted to register this review with the international prospective register of systematic reviews, the PROSPERO database. However, because of the nature of the integrative review, the authors had difficulties registering. A flow chart strategy (Figure 1) was used to depict the process and the final number of selected articles. The authors retrieved 150 published studies, and ten articles were not retrieved. The reasons for the inability to retrieve these reports include the following:
  • Restricted access: some articles were behind paywalls or required institutional access, which was unavailable to the researchers conducting this review.
  • Outdated links: in some cases, the URLs provided for accessing the full texts were outdated or no longer functional, making it impossible to retrieve the articles.
  • Unavailability in digital archives: certain articles were unavailable in digital archives or online repositories, making it challenging to obtain them through standard search methods.
  • Lack of response: attempts were made to contact authors or publishers to request access to the full texts of the article, but in some instances, there was no response, or the requests were denied.
  • Limited availability: some articles may have been published in journals not indexed in the electronic databases searched for this review, resulting in their unavailability through the initial search strategy.
Despite these challenges, efforts were made to maximize the review’s inclusivity by thoroughly screening and retrieving as many relevant articles as possible. Therefore, 54 articles (Figure 1) met the inclusion criteria.
  • Inclusion criteria
The inclusion criteria were studies published in peer-reviewed journals written in English between 2010 and 2023. All studies focused on the mental health challenges faced by sex workers, and all articles discussed the risk factors contributing to the cognitive problems of sex workers.
  • Exclusion criteria
The following studies were excluded from the review:
  • Studies that did not specifically address the mental health challenges encountered by sex workers.
  • Articles not available in the English language.
  • Full-text articles that could not be retrieved.
  • Studies published before 2010.
Psychiatryint 05 00027 g001
Figure 1. Flow chart representing the search strategy.
Figure 1. Flow chart representing the search strategy.
Psychiatryint 05 00027 g001

2.3. Data Evaluation and Quality Assessment

Using techniques for assessing quality criteria, primary sources were carefully evaluated for quality at the data stage [26]. The writers and reviewers conducted a critical examination. A pair of authors (L.W. and G.O.) separately analyzed every final article included. According to Whittemore and Knafl, the sample frame determines the process; there is no gold standard instrument for assessing quality in integrative reviews [26]. One reviewer was consulted for arbitration when necessary to minimize the risk of bias. The authors modified two critical evaluation checklist instruments to evaluate qualitative and quantitative investigations. The modified Qualitative Assessment and Review Instrument (QARI) critical appraisal tool, as shown in Table S1 (Supplementary Materials), was used to evaluate all qualitative investigations, and the quantitative critical appraisal tool was used to appraise all quantitative studies, as shown in Table S2 (Supplementary Materials). The authors also assigned a score out of 10 to each article to evaluate the quality of the investigations; higher scores denoted higher quality. Studies receiving seven or more points were deemed high quality, those receiving five to seven were deemed moderate quality, and those receiving four or fewer were considered low quality. Table 1 below displays the summary of general characteristics of the reviewed studies.

2.4. Data Extraction and Analysis

To produce a thorough conclusion on the study subject under consideration, data from primary sources were categorized, arranged, and summarized during the data analysis phase [24]. The pertinent data were extracted using a data extraction sheet created by the user. It included information about the age range, research methods, psychiatric issues, risk factors contributing to mental challenges, the population under investigation, the variables associated with sex workers, and the findings. The authors of this review used Cresswell’s Tesch method of data analysis and a qualitative content analysis method to address the review issue [24]. It has been established that an integrative review’s analysis can be completed effectively using the qualitative data analysis approach [41]. The writers became acquainted with the literature by reading each piece several times to ensure accuracy. They also related the phenomena in columns with remarks that provided support. Next, the literature was compared with the themes on the list. Thus, to produce a coherent interpretation, the writers organized the data from the quantitative papers into sensible units [42]. Every article was read more than once, and any patterns found were coded. Therefore, subjects with comparable meanings were grouped. These aided in additional classification. Subsequently, every remark that addressed every category was combined. Lastly, grouping related categories allowed for even more data reduction. The authors then decided on the combined codes and compared them to produce the themes and subthemes shown in Table 2. Two authors (L.W. and G.O.) worked on this study independently. A matrix was utilized to present the data during the analytical phase to spot trends and enhance cross-study comparisons. Thus, to reach an agreement on the final products, all authors convened to talk about the themes and subthemes.

2.5. Presentation of Data

The integrative review process concluded with the presentation of data [24,25]. Therefore, the authors provide details from each primary source to provide evidence supporting the conclusions. After being eligible, a sample of 34 papers was chosen for the study from the 150 pertinent publications that the literature search turned up. The findings were combined to provide a comprehensive summary of the state of knowledge regarding the mental health problems that sex workers face. Two main topics emerged from the review. The findings were combined to provide a comprehensive summary of the state of knowledge regarding the mental health problems that sex workers face. Two main topics emerged from the review.

3. Results

This study included only 54 relevant studies. The authors performed a quality appraisal assessment to minimize the risk of bias. They used a Likert scale of 0–10. Most studies scored between 5 and 10, were deemed high-scoring, and maintained high quality. However, most studies adopted a cross-sectional approach, which could have affected the reliability of this study and the methodology used in the systematic review. Most studies recruited female sex workers from a variety of venues, such as the streets and brothels. The majority of the studies attained a score of strong quality. This review found studies conducted in several countries discussing the psychiatric challenges encountered by sex workers. These countries include low-income, lower-middle, and upper middle-income countries. The prevalence of mental disorders among female sex workers in low- and middle-income countries was much higher compared with the general population. Therefore, this distribution suggests significant gaps in the literature, emphasizing the need for more geographically diverse research to understand the psychiatric challenges faced by sex workers globally. The authors used a thematic coding method to formulate themes and subthemes of the review, as depicted in Table 2.
  • Theme 1. Mental health challenges faced by sex workers
The review highlights the mental health challenges that contribute to mental disorders complicating the lives of sex workers.
  • Subtheme 1.1: Mental disorders
The following mental disorders are mental health challenges encountered by sex workers:
  • Depression
One major mental health issue that affects sex workers globally is depression [1,4]. Their experiences with discrimination, stigma, and social marginalization could exacerbate depressive, worthless, and hopeless feelings [1]. Furthermore, the nature of their work, which frequently entails trauma, violence, and exploitation, makes depressive symptoms worse [4,5]. According to two investigations by Rossler et al. and Ranjbar et al., mental disorders and depression were reported by between 30 and 53.5% of sex workers [10,43]. A total of twenty-four studies have examined depression, with estimates ranging from fifty percent to eighty percent [9,20,44]. According to Ouma et al.’s study, the most common symptoms were depressive feelings (62.3%) [45]. Studies on the frequency of depressive symptoms showed varying degrees of severity; mild symptoms were found to be more common in some, while severe symptoms were found to be more common in others [27,28]. Moreover, estimates of the prevalence of major depressive illness ranged from 24% to 61.5% [29]. Notably, in the study conducted in Thailand, Thai transgender women sex workers scored higher in depression, about 86.7%, during the COVID-19 pandemic [29]. Interestingly, a meta-analysis showed a pooled prevalence of depression of 41.8% among female sex workers from low- to middle-income countries [46]. Moreover, few studies also examined depression among female sex workers from low-and middle-income countries [47,48,49,50,51,52,53,54,55,56,57,58,59,60,61].
  • Anxiety
Another common mental health issue among sex workers worldwide is anxiety [1,18]. Anxiety might be increased by the unpredictability, vulnerability, and stigma related to their field of employment [62]. Many people who work in the sex industry are always afraid of being attacked, arrested, or discriminated against, which can cause them to feel anxious, nervous, or overly vigilant [30]. According to a study by Laura Martin-Romo et al., there have been rough studies on anxiety, and the prevalence is high, ranging from 13.6% to 51% [28]. First, in a study by Rössler et al., it was found that female sex workers experienced a one-year prevalence of anxiety of about 33.7% and generalized anxiety of 5.2% [9]. The same study also found a lifetime prevalence of anxiety disorders among female sex workers at a percentage of 34.2% and generalized anxiety of about 7.3% [10]. In another study by Ranjbar et al., 36.7% of sex workers reported to be having anxiety [63]. This is because of the violence and strict laws criminalizing sex work [31,63]. On the other hand, a rise in self-stigma strongly predicted an increase in anxiety [64]. She et al. conducted a similar study to investigate the relationship between transgender sex workers’ (TGSWs) sexual risk behaviors and the consequences of minority stress and mental health. According to this study, anxiety was highly prevalent, which had an impact on TGSWs’ mental health [32]. Therefore, generalized anxiety disorder was the most common disorder reported [65]. Moreover, other studies reported the pooled prevalence of anxiety (21.0%) among female sex workers from low- and middle-income countries [51,54,56,66].
  • PTSD
The risks and traumas that come with working in the sex industry, such as abuse, exploitation, and human trafficking, can cause post-traumatic stress disorder (PTSD), and social marginalization can make these mental health issues worse [33,34]. Sex workers were reported to have PTSD in several studies. This was linked to the stigma attached, discrimination, and violence they experience in their daily lives. Higher levels of PTSD and depressive symptoms were linked to financial difficulty, which included the inability to pay for necessities. This result is related to the fact that poverty is a significant risk factor for subpar mental health outcomes [67]. The percentage of those with PTSD varied from 10% to 39.6% [68]. According to Tschoeke et al.’s study, distance, flashbacks, derealization, and depersonalization were the most reported posttraumatic dissociative symptoms [35]. This study examined dissociation as a coping strategy for childhood sexual abuse due to its effectiveness in addressing traumatic events related to sex work [35]. Moreover, few studies measured psychological distress [31,36,63,64,69].
  • Suicidal ideation and substance abuse disorder
Moreover, 38.8% of sex workers were found to be in danger of committing suicide, according to research that investigated the issue [37]. Suicidal thoughts were reported by 3% to 8% of sex workers [38,70]. A sizable portion of sex workers indicated problematic alcohol usage in terms of substance abuse disorder [71,72]. The findings showed that there are gender disparities in alcohol dependency, with male sex workers having a higher prevalence than female sex workers [39,40]. Additionally, research revealed that the regular use of illegal substances was reported by sex workers, with cocaine being the most often reported drug [73]. It is interesting to note that substance use during sex work was reported by sex workers [73]. Some studies reported a pooled prevalence of recent suicide ideation of 22.8%, while the pooled prevalence of lifetime suicidal ideation was 24.9% [74].
  • Theme 2: Primary risk factors contributing to their mental health challenges
The review highlighted risk factors that contribute to mental health problems among sex workers.
  • Subtheme 2.1 Work and personal associated factors.
Research revealed that a higher risk of post-traumatic stress disorder (PTSD) was linked to more than twenty clients per week [10,27]. It has been discovered that mental health and violence are related. Transgender sex workers reported the most significant rates of violence among all sex workers, with sex workers reporting more violence than the overall population [27]. Workplace violence was linked to an increased risk of depression, PTSD, and suicide, as well as psychological distress [9,11,12]. Moreover, there is evidence linking increased condom abuse to violence [51]. It has been discovered that street-based sex workers are more likely to experience mental health issues. While PTSD levels were higher in one study, street-based sex work was linked to higher levels of depression in another [57].
Poor psychological adjustment has always been linked to a lack of social support. Suicidal thoughts and depression were more common in those who felt there was insufficient social support [31,61]. Similarly, Rossler et al. discovered that inadequate social support, a sense of social exclusion, and a lack of trustworthy individuals were predictive factors of poor psychological adjustment [10]. Moreover, higher mental health issues and more risky sexual behaviors were linked to family rejection [51]. However, other research studies revealed that sex workers evaluated their physical health as worse. Research has indicated a strong correlation between mental and physical well-being, with those in the sex industry who have tried suicide being more likely to experience physical health issues [32]. Additionally, it has been discovered that HIV is linked to worse mental health, including depression and overall psychological suffering [12,45]. For sex workers, age has been linked to mental health issues. The most susceptible group of sex workers were those under the age of twenty, since they showed excellent rates of aggression, substance misuse, depression, and suicidal thoughts and attempts [30]. Less psychological anguish was reported by sex workers between the ages of 21 and 34 [30]. On the other hand, Ouma et al. discovered that depression rates were higher in older sex workers [10].

4. Discussion

In exploring the complexities of sex work and its impact on mental health, this integrative review delves into the multifaceted challenges faced by sex workers. The authors performed a quality appraisal assessment, and most of the studies were of high quality [75,76]. However, most of the studies used a cross-sectional approach, which is likely to affect the reliability of this study. The results of the integrative review shed light on the prevalence of mental disorders among sex workers, including depression, anxiety, PTSD, suicidal ideation, and substance abuse disorder. This review revealed that the prevalence of mental health problems encountered by sex workers is exceptionally high. These findings are consistent with the previous literature, highlighting the vulnerability of sex workers to psychiatric issues [4,5,9]. One critical aspect contributing to these psychiatric challenges is exposure to violence. The literature revealed a strong link between the experiences of violence and the occurrence of mental health disorders. Furthermore, the pervasive stigma surrounding sex work was found to be a cause of psychological distress [31,63,64]. Moreover, the internalization of negative social attitudes led to feelings of worthlessness and shame, exacerbating mental health issues.
Substance abuse among sex workers appeared to serve a dual role. Sex workers demonstrated that they use substances to cope with the intense psychological and physical demands of their work. On the other hand, substance abuse can worsen mental health conditions, creating a vicious cycle of dependency and deteriorating mental health [32]. Research suggests that in countries where prostitution is decriminalized or legal, sex workers may experience reduced stigma and increased access to healthcare and social services, which could positively impact their mental well-being. Conversely, factors such as continued marginalization, violence, and exploitation within the sex work industry may still contribute to mental health challenges regardless of legal status [12].
Moreover, the authors integrated reports from international bodies like SR Health, IE SOGI, and WGDAWG to enrich the discourse on mental health challenges in sex work [12,13,14]. These reports offered valuable insights into the intersection of mental health and human rights within this context. Including these perspectives, these reports enhance understandings of the multifaceted challenges faced by sex workers globally. Therefore, the authors are considering the abolitionist perspective, which views sex work as a form of modern slavery and advocates for its eradication by users and pimps. Additionally, the authors are willing to explore the opposing viewpoint, advocating for the legalization or decriminalization of sex work. Through an analysis of the possible effects of the disparate policy approaches, the authors provide an insight into how various regulatory frameworks might influence the mental health and general well-being of sex workers.
These results highlight the critical need for targeted treatments and destigmatization campaigns to address the mental health needs of sex workers. Furthermore, the discussion underscores the importance of adopting a holistic approach to mental healthcare for sex workers, which considers their unique experiences and challenges. One theory that could strengthen this study is the minority stress theory (MST). This theory posits that individuals from stigmatized or marginalized groups experience excess stress due to their minority status, which can lead to a diverse mental health outcome. In the context of sex work, this theory provides a framework for understanding how societal stigma, discrimination, and social exclusion contribute to the psychiatric challenges faced by sex workers [66]. By integrating MST into the review, researchers can explore how the unique stressors experienced by sex workers impact their mental health. Overall, integrating MST into the study strengthens the theoretical underpinning and explanatory power of the research, offering a framework through which to interpret the complex relationship between sex work and mental health within the broader context of social inequality and marginalization.
This study contributes to the current literature by analyzing the psychiatric challenges faced by sex workers, and it advocates for inclusive mental interventions tailored to this marginalized group. Academically, this study enriches the existing literature by providing a focused analysis of the specific psychiatric issues prevalent among sex workers. By systematically reviewing and synthesizing current research, the study highlighted the prevalence of conditions such as depression, anxiety, and PTSD among sex workers, thereby filling a critical gap in mental health research where this population has been historically underrepresented. Furthermore, the study identifies the methodological strengths and weaknesses of existing research, offering a foundation for future studies to build upon more robust and comprehensive methodologies. On the other hand, the findings of this study have significant implications for mental health practitioners, policymakers, and advocacy groups. Moreover, by elucidating the common psychiatric challenges faced by sex workers, the study underscores the urgent need for targeted mental health interventions and support services tailored to this group. It suggests the development of specialized training programs for mental health professionals to understand and address the unique needs of sex workers. Additionally, this study advocates for policy changes that promote access to mental healthcare for sex workers, including decriminalization and destigmatization efforts, which can reduce barriers to seeking help. Therefore, this study provides a clear roadmap for practical actions that can improve the mental well-being of sex workers and enhance the overall effectiveness of mental health services in this context.

5. Policy Implications

This review highlights the urgent need for policies that prioritize access to mental health services tailored specifically to the needs of sex workers. Historically, this population has faced significant barriers to accessing care due to stigma, discrimination, and legal concerns. The findings suggest several potential avenues for future research and interventions. According to this study, policy implementation should involve a thorough examination of the possible impacts and considerations surrounding the legalization of sex work, considering the complex psychiatric challenges faced by sex workers.

6. Limitations

The limitations of this study include the possibility that it did not include all relevant studies, leading to a potential bias in the findings. The heterogeneity of study methodologies across the included literature may introduce variability and complexity in synthesizing the results. Most of the studies used cross-sectional methods. Language bias is another limitation since the review included studies written only in English. Our search strategy may miss relevant studies. For instance, restricting the search to English-language terms may exclude valuable research conducted in other languages. The study’s scope was narrowed to address the psychiatric challenges faced by sex workers, which means other aspects such as physical health, social issues, or economic factors were not explored in this study. Additionally, publication bias, where studies with positive findings are more likely to be published, can skew the overall conclusions, presenting an overly optimistic view of interventions for psychiatric challenges.

7. Conclusions

In conclusion, this integrative review underscores the multifaceted psychiatric challenges experienced by sex workers, highlighting the intricate intersection of social, economic, and psychological factors in their lives. From stigma and discrimination to trauma and substance abuse, the complexities of their experiences necessitate a comprehensive understanding and tailored interventions. As we strive for greater inclusivity and support for marginalized populations, addressing the mental health needs of sex workers remains a crucial aspect of promoting overall well-being and social justice. Furthermore, this integrative review underscores the importance of adopting a holistic and compassionate approach to understanding and addressing the psychiatric challenges faced by sex workers.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/psychiatryint5030027/s1, Table S1: Modified JBI QARI Critical Appraisal Checklist [75]; Table S2: Quantitative studies critical appraisal checklist [76].

Author Contributions

Conceptualization, M.L.W.; methodology, M.L.W.; validation, M.L.W. and S.G.O.; formal analysis, M.L.W.; investigation, M.L.W.; resources, M.L.W.; data curation, M.L.W.; writing—original draft preparation, M.L.W.; writing—review and editing, M.L.W. and S.G.O.; visualization, M.L.W. and S.G.O.; supervision, S.G.O.; project administration, M.L.W. All the authors have contributed to the work. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

This study did not create or analyze new data, and data sharing does not apply to this research.

Acknowledgments

The authors would like to thank and appreciate the reviewers for their thoughtful comments and for improving this review manuscript. All the reviewers have consented to the acknowledgement.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Summary of general characteristics of the reviewed studies.
Table 1. Summary of general characteristics of the reviewed studies.
Published StudiesResearch MethodologyPopulation (n)Country (Location)Age-Range (Years)OutcomesResearch Quality
Puri et al., 2017 [1].Quantitative692British Columbia≥18Depression, Anxiety.Moderate (5)
Zehnder et al., 2019 [2].Qualitative60Switzerland18 or aboveMental health service use was defined as the use of psychiatric medication, psychotherapy, or substance use services for at least one month during the past six months.Low quality (3)
Ranjbar et al., 2019 [4].Quantitative48Iran18–45High burden of depression.Strong (7)
Millan-Alanis et al., 2021 [5].Systematic review and meta-Analysis55Systematic review>18High prevalence of suicidality, depression, and PTSD among FSWs.Strong (8)
Kanayama et al., 2022 [6].Quantitative403Myanmar16–48Violence perpetrated by clients and threats of violence from partners induces severe symptoms of anxiety and depression.Moderate (5)
Beksinska et al., 2022 [7].Quantitative1039Kenya18–45High levels of persistent suicidal behaviors among FSWs.Strong (10)
Panneh et al., 2022 [8].Qualitative40Kenya18–45The majority of participants understood ‘mental health’ as ‘insanity’, ‘stress’, ‘depression’, and ‘suicide’.Strong (7)
Beattie et al., 2020 [9].Systematic review and meta-analysis68Systematic review11–64A meta-analysis found significant associations between violence experience and depression, violence experience and recent suicidal behavior, alcohol use and recent suicidal behavior, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection.Strong (10)
Rossler et al., 2010 [10].Qualitative2165Cameroon18 or overMediation analysis, both sexual violence and severe depression remained significant predictors of condomless sex.Moderate (6)
Hengartner et al., 2015 [11].Quantitative193Switzerland18–63We found high rates of mental disorders among female sex workers. Additionally, 1-year prevalence rates were high, which points to the immediate burden associated with sex work.Strong (7)
Sagtani et al., 2013 [12].Quantitative88Netherlands20–70Female prostitution has included samples with a high prevalence of substance abuse, violence, and human trafficking.Strong (7)
Hong et al., 2013 [15].Cross-section study1986Southern IndiaAbove 30Almost two-fifths of FSWs (39%) reported significant depression.Strong (8)
Estrada-Tranck, 2023 [16].Cross-sectional1022China>18Partner violence was strongly associated with each of the five measures of psychosocial distress, even after controlling for potential confounders.Moderate (5)
Zhang et al., 2014 [17].Quantitative1022China>18F–G relationship is an independent predictor of the mental health of FSW over and above potential confounders, including partner violence and substance use.Strong (7)
Duff et al., 2017 [18].Qualitative800Canada14 and olderIn multivariable analysis, poor working conditions were associated with increased work stress and included workplace physical/sexual violence.Moderate (5)
Jewkes et al., 2021 [20].Cross-sectional18 or olderSouth Africa30FSWs’ poor mental health risk was often mediated by their work location and vulnerability to violence, substance abuse and stigma.Strong (8)
Beksinska et al., 2021 [21].Cross-sectional qualitative and quantitative1000Kenya18–45Qualitative interviews found that childhood neglect and violence were drivers of entry into sex work and alcohol use and that alcohol and cannabis helped women cope with sex work.Strong (8)
Coetzee et al., 2018 [22].Cross-sectional508South Africa>12Findings highlight the sizable burden of treatable mental health conditions among FSWs in Soweto. This was driven by multiple exposures to violence, sex work-related discrimination and overall moderate levels of self-esteem masking defense mechanisms.Moderate (4)
Poliah and Paruk, 2017 [23]Quantitative624MexicoOlder 18FSW-IDUs identified drug use as a method of coping with the trauma they experienced from abuse.Moderate (5)
Ouma et al., 2021 [27].Cross-sectional300UgandaMore than 20The study underscores the high magnitude of MD driven by multiple sex work-related factors like the presence of a psychosocial stressor, living with HIV, experiencing verbal abuse from clients, and older age.Strong (7)
MacLean et al., 2018 [28].Cross-sectional200Malawi20–24High prevalence of depression, PTSD, and suicide.Moderate (4)
Martín-Romo et al., 2023 [29].Systematic review30Systematic review18–71Mental 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.Strong (7)
Stockton et al., 2020 [30].Cross-sectional729KenyaOver 18Increasing levels of experienced stigma were associated with an increased predicted prevalence of depression.Moderate (5)
She et al., 2021 [31].Cross-sectional204ChinaOver 18The present study identified a high prevalence of co-occurring psychosocial health conditions and sexual risk behaviors.Strong (8)
Teixeira et al., 2017 [32].Quantitative52Portugal18–63Both suicidal ideation and suicide attempts are prevalent in female street sex workers.Moderate (6)
Nabunya et al., 2021 [33].Longitudinal randomized clinical trial542Uganda18–55Women engaged in commercial sex work are at a higher risk of HIV and poor mental health outcomes. Sex work stigma and financial distress elevate levels of depressive symptoms and PTSD over and above an individual’s HIV status.Strong (9)
Tschoeke et al., 2019 [34].Systematic Review554Systematic reviewOver 18Most study participants were street FSWs characterized by high rates of revictimization, a history of childhood sexual abuse, and trauma-related and substance use disorders.Moderate (4)
Mimiaga et al., 2021 [35].Quantitative100USA18 or olderStreet-based MSWs are a vulnerable group for experiencing psychosocial problems and engaging in HIV sexual risk with male clients.Moderate (4)
Fan et al., 2021 [36]Cross-sectional220China18–30Poor mental health status (depressive and anxiety symptoms) is associated with a higher likelihood of SDU in sex work.Moderate (5)
Bitty-Anderson et al., 2019 [37].Cross-sectional2115Ghana18The prevalence of alcohol consumption, hazardous/harmful consumption, and binge drinking was 64.8%, 38.4%, and 45.5%, respectively.Moderate (4)
Su et al., 2014 [38].Qualitative1022China21–34Mental health problems were more prevalent among older and younger FSWs than among medium-aged FSWs.Strong (7)
Carlson et al., 2017 [39].Quantitative222Mongolia>18A linear regression analysis indicated that significant risk factors for depressive symptoms included paying partner sexual violence, perceived occupational stigma, less social support, and higher harmful alcohol use.Strong (9)
Jung 2013 [40].Quantitative1083South Korea18 or olderA higher suicide attempt likelihood was associated with poor sexual and physical health, but there was no significant association with the number of customers per week.Moderate (6)
Table 2. The themes and subthemes of the review.
Table 2. The themes and subthemes of the review.
ThemesSubthemes
1.
Mental health challenges faced by sex workers.
1.1
Mental disorders (depression, anxiety, PTSD, suicidal ideation, and substance abuse disorder).
2.
Primary risk factors contributing to their mental health challenges.
2.1
Work and personal associated factors.
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Winter, M.L.; Olivia, S.G. Life Intricacies of Sex Workers: An Integrative Review on the Psychiatric Challenges Faced by Sex Workers. Psychiatry Int. 2024, 5, 395-411. https://doi.org/10.3390/psychiatryint5030027

AMA Style

Winter ML, Olivia SG. Life Intricacies of Sex Workers: An Integrative Review on the Psychiatric Challenges Faced by Sex Workers. Psychiatry International. 2024; 5(3):395-411. https://doi.org/10.3390/psychiatryint5030027

Chicago/Turabian Style

Winter, Mokhwelepa Leshata, and Sumbane Gsakani Olivia. 2024. "Life Intricacies of Sex Workers: An Integrative Review on the Psychiatric Challenges Faced by Sex Workers" Psychiatry International 5, no. 3: 395-411. https://doi.org/10.3390/psychiatryint5030027

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