Intended for healthcare professionals

Clinical Review

Caring for sex workers

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4011 (Published 05 August 2015) Cite this as: BMJ 2015;351:h4011
  1. Michael L Rekart, clinical professor
  1. 1School of Population and Public Health, University of British Columbia, Vancouver, BC Canada V6T 1Z3
  1. Michael.rekart{at}ubc.ca

The bottom line

  • Ensure vaccinations are up to date (diphtheria-tetanus (DT), measles-mumps-rubella (MMR), meningococcal, influenza, hepatitis A, hepatitis, B and human papillomavirus)

  • Provide regular screening and management for sexually transmitted infections, HIV infection, cervical and anogenital cancer, hepatitis B and C viruses, tuberculosis, and drug, alcohol, and tobacco dependence

  • Improve reproductive health by means of dual contraception, safe abortion, and emergency oral contraception

  • Prevent HIV, sexually transmitted, and blood-borne infections via pre-exposure prophylaxis, post-exposure prophylaxis, condoms, lubricant, needle-syringe exchange programmes, and male circumcision

  • Expedite sexual assault survivor services

  • Ensure comprehensive mental and transgender health care

Sex workers are adults who receive money or goods for sexual services, either regularly or occasionally,1 including female, male, and transgendered sex workers.2 3 Youths under 18 years who sell sex are sexually exploited and not included in the definition.

Caring for sex workers seeking health services requires knowledge, flexibility, open mindedness, and, above all, a non-judgmental attitude. Practitioners can be directly involved in curing communicable diseases, preventing chronic conditions, and helping patients through a sometimes difficult period. Sex workers are at higher risk of many conditions (box 1), but they may also have ongoing chronic disease issues. This article provides an evidence based review (see box 2 for details of data search) of the specific health needs of sex workers, aimed at non-specialist hospital doctors, general practitioners, and candidates for postgraduate examinations globally.

Box 1: Health issues for sex workers

  • HIV infection—Evidence from systematic reviews and meta-analyses4 5 6 7

  • Sexually transmitted infections (gonorrhoea, chlamydia, syphilis, herpes (HSV-2), trichomonas, human papillomavirus)—Evidence from analytical and observational studies2 8 9 10 11 12 13 14 15 16 17

  • Complications of sexually transmitted infections (pelvic inflammatory disease and ectopic pregnancy)—Evidence from analytical and observational studies2 8 9 10 11 12 13 14 15 16 17

  • Hepatitis A, B, and C—Evidence from observational studies18 19 20 21 22 23 24

  • Tuberculosis—Expert opinion24 25

  • Unmet contraceptive need, unplanned pregnancy, unsafe abortion, inadequate pregnancy care, newborn complications—Evidence from cross sectional surveys, case series, and qualitative studies16 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

  • Non-injected and injected drug use, alcohol dependence, tobacco use—Evidence from systematic reviews and meta-analyses, analytical and observational studies40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59

  • Physical violence, especially rape—Evidence from cohort studies, case series, cross sectional surveys2 3 60 61 62 63 64 65 66

  • Mental health disorders (depression, suicidality, post-traumatic stress disorder)—Evidence from cross sectional surveys, case series, observational studies2 3 16 24 25 41 42 43 44 55 60 67 68 69 70 71 72

Box 2: Sources and selection criteria

I searched PubMed, Embase, PsychInfo, Social Work Abstracts, Social Science Abstracts, and Web of Science using the terms “prostitution,” “risk reduction,” “sex work,” “sex worker,” “sex trade,” “prostitute,” “survival sex,” “transactional sex,” and “harm reduction.” Reference lists from selected articles and widely used textbooks on HIV and sexually transmitted infections were reviewed. I consulted the BMJ Group’s Clinical Evidence series and the Cochrane Collaboration.

With the key words above, I searched non-peer reviewed work using Google; websites and publications of the United Nations (UN), Joint United Nations Programme on HIV/AIDS (UNAIDS), and World Health Organization (WHO); and information from select non-governmental organizations. I chose articles according to the following hierarchy: meta-analyses, randomised controlled trials, analytical studies, systematic reviews, observational studies, UN, UNAIDS, and WHO publications, commentaries, and editorials. Large studies were preferred. Using the Journal Citation Reports database, I prioritised high impact journals. Non-peer reviewed work was searched for additional issues.

What happens when sex workers access health care?

Sex workers often hide their involvement in sex work and drug use due to fear of being judged and treated poorly.3 47 73 74 75 76 77 When they disclose their occupation, they often experience stigmatising behaviour from staff, disapproval, shaming, other patients staring, and questioning about their work in a sexualising and degrading manner.47 73 76 77 Many health workers have limited training on sex work and do not know how to deal with sex related issues in general.73 77 78 79

Sex workers often face structural barriers to accessing health care such as long waits, restrictive hours, unwelcoming spaces, fear of arrest, legal status requirements, inconvenient location, lack of transportation, inability to pay, lack of confidentiality, and no access to a social worker.73 77 80 81 82

Resources permitting, many sex workers in low-resource settings will attend private services, citing quality, respect, and confidentiality.83 84 85 However, most will attend good quality, affordable public clinics if they are available.73 75 77 82 86 Where sex workers, especially injecting drug users, experience barriers, a common strategy is to go to a hospital emergency room.73 74 77 87 When no alternatives are available, sex workers may self medicate; consult traditional healers, drug store operators, pharmacists, street vendors, or friends; travel home for treatment; delay treatment; or not seek care at all.73 77 82 83 86 88

Access to a non-judgmental family doctor is one of the main issue facing sex workers, and some never see a healthcare provider.73 77

What preventive health measures are available to sex workers?

Vaccination

Close contact with clients of unknown vaccination status means that sex workers should be up to date for diphtheria-tetanus (DT), measles-mumps-rubella (MMR), meningococcal, influenza, hepatitis A, and hepatitis B vaccination.19 24 27 89 90 91 Human papillomavirus infection is causally related to cervical, anogenital, and oral neoplasms. Human papillomavirus vaccine protects against type-specific, pre-neoplastic genital lesions and genital warts in unexposed females and males. International vaccination schedules vary but, where feasible, sex workers should be offered this vaccine.14 15 16 90 92 93 94 95

Regular screening for sexually transmitted infections, cancer, and tuberculosis

Sexually transmitted infections are often asymptomatic, and delayed treatment can lead to pelvic inflammatory disease and ectopic pregnancy.8 9 10 11 12 13 14 15 16 17 24 25 In randomised controlled trials regular screening of sex workers reduces the incidence of sexually transmitted infection and HIV infection, increases condom use, and prevents sexually transmitted infection complications.24 96 97 98 99 100 101 102 103

In a Côte d’Ivoire prospective cohort study, monthly screening of female sex workers by means of interview, vaginal examination (bimanual, external, and speculum), and microscopy significantly reduced HIV, chlamydia, and gonorrhoea infections and increased consistent condom use.102 Voluntary screening for sexually transmitted infection received sex worker support in a global consultation83 and a Madagascar study.104 Cervical cancer screening using a Pap smear test, visual inspection with acetic acid, or human papillomavirus testing promotes early detection and treatment, reducing morbidity and mortality.24 105 Anal Pap smear testing is also feasible.106

The WHO recommends that sex workers be offered periodic screening for asymptomatic sexually transmitted infections24 and 3-yearly cervical cancer screening.105 For HIV-infected sex workers, the WHO recommends annual cervical cancer screening and periodic tuberculosis screening.24

HIV voluntary counselling and testing

HIV infection often goes undetected. Analytic studies show that provider-initiated voluntary counselling and testing facilitates diagnosis, behaviour change, and access to HIV related services.83 97 107 108 109 A meta-analysis of voluntary counselling and testing recipients in low income countries showed a significant reduction in unprotected sex.108 However, most sex workers in low resource settings have not been tested for HIV infection.24 109 110 The WHO recommends voluntary counselling and testing whenever a sex worker requests it, at least annually.24

HIV post-exposure prophylaxis

A Cochrane review supports post-exposure prophylaxis for occupational exposure to HIV,111 and guidelines for 28 days of two or three antiretroviral agents started within 72 hours are available.112

Because the probability of HIV transmission via unprotected sex and needle sharing is similar to occupational exposure, post-exposure prophylaxis should be offered to eligible sex workers experiencing an unplanned exposure (sexual or via injected drug use) to an HIV infected person.113 114 115 116 For exposure to someone of unknown HIV status, the provider and sex worker should jointly decide, based on local HIV prevalence, exposure type, and factors such as trauma and co-existent sexually transmitted infections.114 Rape survivors should be prioritised for post-exposure prophylaxis because of the likelihood of genital injuries and to help overcome psychological trauma.114

Post-exposure prophylaxis after unplanned insertive sexual exposure has not been studied. Post-exposure prophylaxis after regular sexual exposure might lead to continuous antiretroviral prophylaxis that may be ineffective and toxic. Post-exposure prophylaxis is not indicated for oral sex.

HIV pre-exposure prophylaxis

Pre-exposure prophylaxis refers to preventing HIV acquisition via sexual services or injected drug use by using antiretrovirals ahead of time.117 118 119 Two large and scientifically-sound meta-analyses showed a decrease in HIV risk approaching 92% with good adherence to daily oral pre-exposure prophylaxis with tenofovir or tenofovir-emtricitabine combination, and 39% for coitally timed tenofovir 1% vaginal gel.117 118 119 120 Studies were conducted in populations of sex workers, men who have sex with men, transgender women, heterosexuals, and injecting drug users.107 119 120 121 122 There was no relationship between transactional sex and HIV incidence or pre-exposure prophylaxis adherence.107 120 121

Sex workers are at high risk of HIV acquisition because of their vulnerability, lack of control over condom use, and low risk perception with intimate partners.107 The WHO and Centers for Disease Control (CDC) recommend that sex workers be offered daily oral pre-exposure prophylaxis with tenofovir-emtricitabine or tenofovir-lamivudine, which are equivalent.123 124 125 126 Limited data show no adverse effects of tenofovir-emtricitabine in pregnancy or during breast feeding, but there are no data on the long term health effects in HIV uninfected individuals.119 123 125

Pregnancy prevention

Female sex worker surveys in Tanzania and Madagascar estimated pregnancy rates from 17.8 to 53.0 per 100 person-years.127 128 129 Unfortunately, sex worker pregnancies are often unintended, and in some countries this leads to unsafe abortions.17 24 25 35 38 39 127 128 129 130 131 132 133 134 135 This often reflects a reliance on condoms alone to prevent pregnancy.38 Observational studies report inadequate knowledge, access, and use of non-condom contraception by sex workers despite the importance of preventing pregnancy.38 39 127 128 131 Sex workers should be offered a dual method of contraception, such as long acting intramuscular progesterone or oestrogen implant, oral contraceptives, intrauterine device, or diaphragm.4 38 39 40 127 129 131

Sex workers should be made aware of the emergency oral contraceptive (“morning after pill”) and that it is effective up to 72-120 hours after unprotected intercourse.24 In the event of pregnancy, sex workers require regular voluntary counselling and testing and sexually transmitted infection screening because many will continue to work and may be unaware of vertical transmission of HIV and sexually transmitted infections.136

Male circumcision

Three randomised controlled trials have shown that circumcision for heterosexual men reduces acquisition of HIV and other sexually transmitted infections and penile cancer.98 137 138 139 140 141 142 A systematic review and subsequent observational studies in men who have sex with men show that circumcision protects the insertive but not the receptive partner from sexually transmitted infections and HIV.141 143 144 145 146 Male circumcision may protect heterosexual women from non-HIV sexually transmitted infections.137 147 148

Safe sex promotion and needle-syringe programmes

An extensive Cochrane review of male condoms for reducing heterosexual HIV sexual transmission yielded a 0.17 risk ratio.149 Analytical studies have shown that female condoms prevent pregnancy and sexually transmitted infections, and there is in vitro evidence and biological plausibility for prevention of HIV infection.2 150 151 Prospective observational cohort studies show that promoting male condoms to sex workers decreases sexually transmitted infections and HIV infection2 83 97 98 107 152 and adding female condoms provides additional protection.97 150 151

For anal sex among men who have sex with men and transgender people, a WHO systematic review concluded that male condoms reduced HIV transmission by 64% and transmission of sexually transmitted infections by 42%.152 153 154 155 However, slippage and breakage are increased.156 Studies of female condoms for anal sex among men who have sex with men showed slippage, pain, and rectal bleeding,157 and there are no transmission studies of HIV or sexually transmitted infection.

Studies have found that use of water soluble lubricants with male condoms is acceptable to sex workers and reduces breakage, pain, and trauma,2 3 83 97 155 156 but non-water based lubricants increase male condom failure.83 152 158 159 Lubricants without condoms increase sexually transmitted infection risk.152 159 160 Vaginal and rectal microbicide research in sex workers is under way, but tenofovir vaginal gel has low tolerability when applied rectally.98 152 This author recommends against microbicides.

Drug injecting sex workers should have access to needle-syringe programmes to prevent HIV and bloodborne virus transmission.24

What are the treatment needs of sex workers?

Universal antiretroviral therapy

The WHO currently recommends antiretroviral drugs for HIV infected adults and adolescents with a CD4 count ≤500×106 cells/L, clinical stage 3-4, and those in sero-discordant relationships.161 This argues for universal antiretroviral therapy for all HIV positive sex workers regardless of CD4 count or clinical status because their occupation necessarily involves HIV sero-discordant liaisons. By offering antiretroviral therapy to all HIV infected sex workers whenever they are ready, millions of HIV infections can likely be averted, and the potential reduction in morbidity and mortality is enormous.42 107 124 162 163 164 165

Early antiretroviral therapy also benefits individuals by suppressing viral replication, normalising T cells, and reducing non-HIV comorbidities, AIDS progression, and death.164 166 167 168 169 170 171 172 173 174 175 176 177 178 Two large randomized, controlled prospective cohort studies in Africa showed highly significant reductions in death, serious illness and progression to AIDS in patients starting ARVs at >500 CD4 cells/mm3 versus patients started at <200-350 cells/mm3 or when they were diagnosed with an AIDS-defining illness.179 180

Enhanced treatment of sexually transmitted infection

Studies show that treating sexually transmitted infections in sex workers decreases morbidity, prevents transmission of HIV and sexually transmitted infection, and reduces complications of sexually transmitted infection.2 24 25 97 107 155 181 182 183 Treatment of sexually transmitted infection among sex workers should be prompt, evidence based, and acceptable. Single dose oral regimens are preferable.

In resource poor settings, syndromic management of sexually transmitted infections identifies common syndromes based on history and guides treatment based on local epidemiology.155 182 However, effectiveness is poor for vaginal discharge and unknown for anorectal syndromes.24 97 107 155 181 184 Sex workers’ physicians can do better by performing external and internal vaginal and rectal examinations. Candidiasis is diagnosed by vulvovaginal redness, and cervicitis produces visible cervical mucopus and easy bleeding. Painful anal discharge is usually caused by herpes simplex virus 2, and painless discharge by gonorrhoea or chlamydia. Treatment after genital examination can be more targeted and safer.

Periodic presumptive treatment is one to six monthly antibiotic prophylaxis for curable sexually transmitted infections based on risk and prevalence.24 97 A meta-analysis of research with female sex workers showed benefit,185 186 but periodic presumptive treatment is unacceptable to many sex workers who fear stigmatisation, antibiotic resistance, and difficulty maintaining condom use.83 97

Access to safe abortion

There are 22 million unsafe abortions annually accounting for 47 000 deaths and five million disabilities.133 In a large survey of Kenyan female sex workers, 86.1% reported an unplanned pregnancy ending in unsafe abortion, and 50.9% reported two.35

In low resource settings, hospital based surgical abortions are often unavailable, but oral mifepristone and/or misoprostol are commonly used for safe medical abortion.133 134 135 187 188 The WHO supports use of these oral synthetic prostaglandins , and low doses are safe and effective throughout pregnancy.133 189 190 191 Where practitioners do not feel competent to prescribe and monitor medical abortion, they should provide information on abortion options to female sex workers and prompt referral to trained abortion providers. They should also be aware that many pregnant women in low resource settings can and will access misoprostol without a prescription.

Caring for survivors of sexual assault

Rape is the physically forced or otherwise coerced penetration of the vulva or anus with a penis, other body part, or object.192 Sex workers’ doctors need to be aware of local protocols to provide expedited care for sexual assault survivors (box 3) because they are frequent targets of coerced sex and rape.192 193 194 195 196 197

Box 3: Care for sexual assault survivors24

  • Provide private, confidential, and supportive first line assessment urgently

  • Take a history and offer to do a full physical examination

  • Offer HIV post-exposure prophylaxis if the rape occurred within 72 hours, if the patient’s HIV status is uninfected or unknown, and if he or she is not using HIV pre-exposure prophylaxis

  • Offer emergency oral contraceptive if the rape occurred within 120 hours even if the patient is using dual or hormonal contraception

  • Offer single dose oral sexually transmitted infection prophylaxis for chlamydia, gonorrhoea, and trichomonas—such as 2 g azithromycin + 800 mg cefixime + 2 g metronidazole

  • Encourage immediate and follow-up syphilis testing (cefixime + azithromycin may cure incubating syphilis, but neither is first line therapy so screen and retest)

  • Offer vaccination for hepatitis B or hepatitis A and B if the patient is not known to be immune

  • Offer referral to a supportive social worker, psychologist, or legal resource

  • Keep a confidential record of the visit, with the patient’s consent

  • Offer to support sex workers who decide to report the rape to the authorities

  • Provide ongoing support and follow-up care as needed for at least three months

  • Watch for post-traumatic stress disorder and arrange appropriate therapy

Mental wellbeing

Mental health is strongly influenced by environmental factors and social circumstances including stigmatisation. Thus, sex workers are particularly vulnerable to mental health problems24 that may complicate prevention, treatment, and continuing care. Many surveys and observational studies of sex workers report depression, self harm or suicide, anxiety, and post-traumatic stress disorder.25 26 41 42 43 44 56 61 67 68 69 70 71 72 198 199 In one multi-country survey, 68% of 854 sex workers met the diagnostic criteria for post-traumatic stress disorder.200

WHO’s mhGAP (Mental Health Gap Action Programme) Intervention Guide provides step-by-step assessment and management flowcharts for care, psycho-education, adjunct treatments, and pharmaceutical interventions including antidepressants, antipsychotics, and benzodiazepines.201

Transgender health

Transgender sex workers face special challenges from hormone and silicone use, gender reassignment surgery, and transphobia.3 6 13 18 41 42 44 64 65 72 155 202 203 204 205 Most transgender sex workers live as their self identified gender, making hormone treatment the most important gender enhancement practice.44 65 72 155 205 Stigmatisation forces many to obtain hormones illicitly and self inject.24 42 155 205 Injected silicone can be fatal.65 155 Medically supervised hormonal therapy facilitates healthcare engagement, including safe injecting and antiretroviral therapy adherence.42 44 206 For transgender women who undergo vaginoplasty, condoms with water-based lubricant are especially important.42

Hepatitis treatment

Sex workers have elevated rates of infection with hepatitis C and B viruses.18 19 20 21 22 23 24 Both can be effectively treated to reduce morbidity and mortality.161 207 208 209 210 211 Eligible sex workers should be referred to appropriate providers who can prescribe and monitor treatment.

Drug and alcohol dependence

Sex workers report high rates of non-injection and injecting drug users, alcohol dependence, and tobacco use.2 3 24 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 Prospective and retrospective studies demonstrate that agonist outpatient opioid substitution therapy is safe and cost effective at reducing drug use, needle sharing, HIV and bloodborne virus transmission, overdose, criminal activity, health risks in pregnancy, and initiation into injecting.24 201 212 213 214 215 216 217 Antiretroviral therapy and needle-syringe programmes enhance these benefits.213 The WHO recommends that opioid dependent sex workers should have access to opioid substitution therapy including “take home” naloxone for overdose. Health professionals seeing sex workers should be familiar with local procedures to help them gain access to this treatment.218 Cocaine, amphetamine-type stimulant, benzodiazepine, and alcohol dependence management is delineated in WHO’s mhGAP guide.201

How can healthcare services be tailored to sex workers’ needs?

  • Non-judgmental attitudes—The most important quality that sex workers want in their health provider is a non-judgmental attitude toward sex work, sexuality, and drug use.3 34 73 77 82 83 85 214 215 216 217 218 219 220 221 Respect, acceptance, and patience are critical attributes.

  • Sex worker-friendly services—Sex workers often feel alienated by clinic spaces and office atmospheres and excluded by structural barriers.73 77 80 81 82 83 220 221 Offices and services can be made sex worker-friendly in the following ways:

    • Ask local sex worker community groups for advice

    • Offer convenient opening hours, such as a regular evening clinic

    • Shorten wait times by giving sex workers priority at certain times

    • Arrange sessions only for sex workers or for certain language or cultural groups

    • Hire staff who can act as interpreters or cultural mediators

    • Provide childcare or a child-friendly waiting area

    • Have supportive social workers onsite or nearby

    • Employ transgender people, gay men, or sex workers themselves

    • Consider peer based managed or co-managed clinics and programmes

    • Make the waiting area inviting with information addressing sex worker concerns, such as nutrition, confidentiality, navigating the health system, and reproductive health

    • Use screening questions that don’t unnecessarily pry into patients’ private lives

    • Separate the front desk from the waiting room so other patients cannot overhear

    • Try innovative strategies such as emergency drug pickups and patient-held records

    • Allow flexible payment options such as sliding scale services

  • Shared decision making—Providers should be flexible and client centred when developing a care plan by involving sex workers in decisions based on simple and clear education materials addressing their issues. Sex worker services often provide general information, but few focus on concerns specific to sex workers.3 24 73 77 83 222 Some patients will benefit from empowerment training and support from sex worker community groups.

  • Screened and affirming referral network—A “one stop shop” for sex workers is not usually feasible. Their doctors need a high quality, unprejudiced referral network, including medical and addictions specialists, nutritionists, legal and immigration advocates, housing and social workers and practitioners of alternative medicine (such as acupuncture, naturopathy, meditation, and massage therapy).3 73 77 83

Questions for future research

  • What is the impact of decriminalisation or legalisation on sex worker health?

  • Ongoing trials among female sex workers will identify whether sex worker-related factors could alter the effectiveness of pre-exposure prophylaxis—such as sex frequency, lubrication, trauma, and concurrent sexually transmitted infections.

  • Ongoing research will assess the effectiveness of vaginal and rectal microbicides.

  • Do female condoms reduce HIV and sexually transmitted infection transmission during anal sex?

  • Do female condoms reduce heterosexual HIV transmission?

  • Do sex workers require pneumococcal vaccination?

  • Is human papillomavirus vaccine safe and effective when it is given in a two dose schedule?

  • Should post-exposure prophylaxis be used for unexpected insertive sexual exposure?

  • Does male circumcision reduce HIV acquisition for male sex workers and transgender sex workers engaging in penile-vaginal and penile-anal sex?

  • Is sexually transmitted infection syndromic management effective for anorectal syndromes?

  • Is empiric treatment for sexually transmitted infection useful after unprotected sex with a symptomatic partner?

  • For people who fail opioid substitution therapy, will supervised self administration of injectable diacetylmorphine or hydromorphone be effective?

Additional educational resources

Resources for patients seeking information, support, referral, and empowerment
Resources for healthcare professionals

How were patients included in the creation of this article?

  • The Network of Sex Work Projects reviewed an early draft of the article and provided helpful suggestions.

Notes

Cite this as: BMJ 2015;351:h4011

Footnotes

  • I thank the Network of Sex Work Projects and Dr Xandra Rardon for reviewing the manuscript and making valuable suggestions for revision.

  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

References

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