Mental health problems among female sex workers in low- and middle-income countries: A systematic review and meta-analysis
The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. Thi...
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Published in | PLoS medicine Vol. 17; no. 9; p. e1003297 |
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Main Authors | , , , |
Format | Journal Article |
Language | English |
Published |
United States
Public Library of Science
01.09.2020
Public Library of Science (PLoS) |
Subjects | |
Online Access | Get full text |
ISSN | 1549-1676 1549-1277 1549-1676 |
DOI | 10.1371/journal.pmed.1003297 |
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Abstract | The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.
The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.
In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs. |
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AbstractList | The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.BACKGROUNDThe psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.METHOD AND FINDINGSThe review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs.CONCLUSIONSIn this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs. In addition to the social determinants described earlier, women who sell sex face a unique set of structural factors including police harassment and arrests, discrimination, marginalization, poverty, and gender inequality [8,9], as well as extreme occupational hazards such as violence, coercion, deception, alcohol and substance use, and human immunodeficiency virus (HIV)/sexually transmitted infection (STI) [10]. Search terms included the following: “mental health” OR “mental well-being” OR “psycholog* health” OR “psycholog* distress” OR “mental illness*” OR “mental disorder*” OR “mental health problem*” OR “psychiatr* morbidit*” OR “anxiety” OR “depress*” OR “suicid*” OR “trauma” OR “post-traumatic stress disorder” OR “PTSD”; “sex work*” OR “female sex work*” OR “prostitut*” OR “female prostitut*” OR “sex trad*” OR “transact* sex” OR “FSW*” OR “commercial sex” OR “sex-trade worker*”; “low and middle income countr*” OR “LAMIC*” OR “LMIC*” OR “developing countr*” OR “names of all countries which fit the LMIC criteria.” Eligible studies had to be peer-reviewed, include females aged 16 or older who were actively engaged in sex work, and include the following study designs: cross-sectional survey, case–control study, cohort study, case series analysis, or experimental study with baseline measures for mental health. Meta-analyses were conducted on studies that scored moderate to strong in the quality assessment and that used validated measures to assess mental health outcomes; we excluded studies from the meta-analyses that sampled participants based on characteristics that are known to be an independent risk factor for mental health problems (such as injecting drug use or HIV status) and could therefore bias the pooled mental health estimates. In addition to the social determinants described earlier, women who sell sex face a unique set of structural factors including police harassment and arrests, discrimination, marginalization, poverty, and gender inequality [8,9], as well as extreme occupational hazards such as violence, coercion, deception, alcohol and substance use, and human immunodeficiency virus (HIV)/sexually transmitted infection (STI) [10]. Search terms included the following: “mental health” OR “mental well-being” OR “psycholog* health” OR “psycholog* distress” OR “mental illness*” OR “mental disorder*” OR “mental health problem*” OR “psychiatr* morbidit*” OR “anxiety” OR “depress*” OR “suicid*” OR “trauma” OR “post-traumatic stress disorder” OR “PTSD”; “sex work*” OR “female sex work*” OR “prostitut*” OR “female prostitut*” OR “sex trad*” OR “transact* sex” OR “FSW*” OR “commercial sex” OR “sex-trade worker*”; “low and middle income countr*” OR “LAMIC*” OR “LMIC*” OR “developing countr*” OR “names of all countries which fit the LMIC criteria.” Eligible studies had to be peer-reviewed, include females aged 16 or older who were actively engaged in sex work, and include the following study designs: cross-sectional survey, case–control study, cohort study, case series analysis, or experimental study with baseline measures for mental health. Meta-analyses were conducted on studies that scored moderate to strong in the quality assessment and that used validated measures to assess mental health outcomes; we excluded studies from the meta-analyses that sampled participants based on characteristics that are known to be an independent risk factor for mental health problems (such as injecting drug use or HIV status) and could therefore bias the pooled mental health estimates. The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors. The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors. In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs. BackgroundThe psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.Method and findingsThe review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.ConclusionsIn this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs. Tara Beattie and co-workers assess the evidence on mental ill-health in female sex workers in low- and middle-income countries. |
Author | Mazzuca, April Smilenova, Boryana Krishnaratne, Shari Beattie, Tara S. |
AuthorAffiliation | 1 Department of Global Health and Development, The London School of Hygiene & Tropical Medicine, London, United Kingdom 3 School of Population and Public Health, University of British Columbia, Canada 2 King’s Health Partners, Guy’s Hospital, London, United Kingdom Harvard Medical School, UNITED STATES |
AuthorAffiliation_xml | – name: 1 Department of Global Health and Development, The London School of Hygiene & Tropical Medicine, London, United Kingdom – name: 2 King’s Health Partners, Guy’s Hospital, London, United Kingdom – name: 3 School of Population and Public Health, University of British Columbia, Canada – name: Harvard Medical School, UNITED STATES |
Author_xml | – sequence: 1 givenname: Tara S. orcidid: 0000-0001-9156-7341 surname: Beattie fullname: Beattie, Tara S. – sequence: 2 givenname: Boryana surname: Smilenova fullname: Smilenova, Boryana – sequence: 3 givenname: Shari orcidid: 0000-0001-9053-5065 surname: Krishnaratne fullname: Krishnaratne, Shari – sequence: 4 givenname: April orcidid: 0000-0002-8843-3745 surname: Mazzuca fullname: Mazzuca, April |
BackLink | https://www.ncbi.nlm.nih.gov/pubmed/32931504$$D View this record in MEDLINE/PubMed |
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ContentType | Journal Article |
Copyright | 2020 Beattie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. 2020 Beattie et al 2020 Beattie et al |
Copyright_xml | – notice: 2020 Beattie et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. – notice: 2020 Beattie et al 2020 Beattie et al |
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DOI | 10.1371/journal.pmed.1003297 |
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Snippet | The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk... In addition to the social determinants described earlier, women who sell sex face a unique set of structural factors including police harassment and arrests,... Tara Beattie and co-workers assess the evidence on mental ill-health in female sex workers in low- and middle-income countries. BackgroundThe psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs).... |
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SubjectTerms | Acquired immune deficiency syndrome Adolescent Adult Aggression AIDS Alcohol Anxiety Anxiety Disorders Biology and Life Sciences Child Cross-Sectional Studies Developing Countries Domestic violence Drug use Earth Sciences Estimates Female Females HIV HIV Infections - epidemiology Human immunodeficiency virus Humans Low income groups Medicine and Health Sciences Mental depression Mental disorders Mental Health Mental health care Meta-analysis Middle Aged Occupational hazards Physical Sciences Post traumatic stress disorder Poverty Prevalence Prostitution Quality control Research and Analysis Methods Risk Factors Safe Sex Search strategies Sex Sex industry Sex Workers - psychology Sex Workers - statistics & numerical data Sexual Behavior Sexually Transmitted Diseases - epidemiology Social Sciences Stress Disorders, Post-Traumatic - epidemiology Stress Disorders, Post-Traumatic - psychology Substance use Suicidal Ideation Suicide, Attempted Suicides & suicide attempts Systematic review Trauma Violence Workers |
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Title | Mental health problems among female sex workers in low- and middle-income countries: A systematic review and meta-analysis |
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