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 inPLoS medicine Vol. 17; no. 9; p. e1003297
Main Authors Beattie, Tara S., Smilenova, Boryana, Krishnaratne, Shari, Mazzuca, April
Format Journal Article
LanguageEnglish
Published United States Public Library of Science 01.09.2020
Public Library of Science (PLoS)
Subjects
Online AccessGet full text
ISSN1549-1676
1549-1277
1549-1676
DOI10.1371/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.
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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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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http://dx.doi.org/10.1371/journal.pmed.1003297
Volume 17
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