Author : Dr. Shivali Sachin Gainewar
Clinical psychologist
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The phenomenon of healthcare and social struggles among sex workers in communities of South Africa is a critical concern. Sex workers are often stigmatised, discriminated against, and violated. This study stems from the observation that sex workers experience daily healthcare and social challenges due to their line of work. This involves prejudice and stigma from the general public and medical professionals. Despite government efforts to raise the calibre of healthcare services, some healthcare systems remain problematic.
Objective:
The study intended to critically review the publications on public health problems and barriers faced by sex workers.
Methodology:
The systematic review methodology was used in the investigation. Identification of the problem, literature search, data evaluation, data analysis, and presentation were the five stages of the systematic review that were carried out.
Results:
The analysis yielded two themes and seven subthemes: (1) public social problems that sex workers must navigate, including violence, criminalisation of sex work, stigma, prejudice, and linguistic and cultural hurdles, (2) high rates of HIV and STIs, a lack of comprehensive knowledge of reproductive and health issues, problems with mental health, and challenging access to care are some examples of the complexity of public healthcare. In conclusion, sex workers in South African communities face complex and varied social and health challenges. A multi-pronged strategy, including legal change, destigmatisation, and improved access to healthcare and social support services, will be needed to address these problems. To ensure that sex workers can receive the treatment and services they need to maintain healthy and satisfying lives, healthcare providers and policymakers must collaborate.
Conclusion:
A multipronged approach, including legal reform, destigmatisation, and increased access to healthcare and social support services, is required to address the healthcare and social struggles of sex workers.
Violence:
Sex workers are at increased risk of violence, including physical assault, rape, and arrest and incarceration, with underreporting and lack of prosecution contributing to a sense of vulnerability and helplessness among sex workers . Similarly, sex workers face a significant risk of violence from clients and the broader community due to the stigmatisation of sex work and the criminalisation of many aspects of the industry . This violence can take many forms, including physical and sexual assault, verbal harassment, extortion, and trafficking, and sex workers may be reluctant to report crimes to the police due to fear of arrest . Sometimes, police officers can also perpetrate physical abuse, particularly in countries where sex work is illegal. These acts of violence can cause severe injuries, leading to long-term physical and mental health problems . Sexual violence is also a significant risk for street sex workers. Clients can force them to perform sexual acts against their will or without using protection, putting them at risk for sexually transmitted infections . Pimps or other individuals may also subject street sex workers to rape or sexual assault . Many sex workers are also vulnerable to human trafficking and forced prostitution, particularly heinous sexual violence. Extreme sexual violence against male, female, and transgender sex workers has been observed, particularly during arrest and custody, and includes gang rape and forced unprotected intercourse . Sixty percent of Adama, Ethiopia, sex workers reported experiencing workplace violence . It was 79% in Mombasa, Kenya, compared to 16% in Hunan, China, and 9% in Karnataka, India, where female sex workers reported work-related violence . This shows how most sex workers experience abuse at work. Pimps, police officers, and people who purchase sex from sex workers are some of the people who commit violent crimes.
Criminalisation of Sexual Work:
Criminalisation is the process by which behaviours and individuals are transformed into crimes and criminals . Criminalisation is a significant barrier to healthcare for sex workers. In many countries, sex work is illegal, which means that sex workers may be afraid to seek medical care for fear of being arrested or prosecuted . This fear can lead to a lack of trust in healthcare providers and a reluctance to disclose sensitive information. Furthermore, criminalisation may make it more challenging for sex workers to obtain medical care, including HIV testing and treatment .
Laws that make sex work illegal can make it harder for young people to manage the terms under which sex is sold and deter them from using services out of concern that they would be detained, arrested, or prosecuted . These laws are frequently enforced punitively through the seizure of identity documents and citizenship rights, mandatory or coerced HIV testing, condoms being seized, which are used as evidence of solicitation, and the lack of protection from the workforce . In Kenya, police use the possession of condoms as evidence of sex work, leading to the arrest of the individual and the confiscation of their condoms . In Zimbabwe, a group of sex workers said that their interactions with the police were complex and that they had taken their condoms away, placing them in danger as they tried to make a living . According to a 2019 investigation, approximately 15000 sex workers were housed in facilities dubbed “custody and education centres” .
Similarly, a new law in Cambodia that is supposed to combat sex workers has suffered because of sexual exploitation and human trafficking . Police have utilised the law to shut down brothels, moving sex workers to unregulated nightclubs and public places . The ability of female sex workers to negotiate condom use had decreased due to their displacement, which also exposed them to more violence and restricted their access to assistance.
Stigma and Discrimination:
The sociologist Erving Goffman defined stigma as a social trait or mark that separates individuals based on socially generated opinions . Stigmas severely diminish the bearer, turning them from a whole and well-liked person to a flawed and dismissed one . contended that in the case of sex workers, the outcome is frequently a refusal to use health services since the identity of the sex workers is elevated to a significant status. When sex workers seek medical care, attitudes and animosity are frequently present because even healthcare professionals and medical facilities worry about being stigmatised by association . As a result, other residents’ social rights are sometimes denied to sex workers . According to Benoit , prejudice is the root cause of structural inequality in society, increasing vulnerability and, to some extent, the weight of avoidable health issues for marginalised groups. Society often views sex work as immoral, illegal, or dirty . This stigma may result in a lack of trust between sex workers and medical professionals. Many sex workers fear judgment, discrimination, or even violence when accessing healthcare . As a result, they may avoid seeking care altogether, even when they need it. Sex work is stigmatised and associated with immorality, leading to discrimination and social isolation and creating a hostile healthcare environment .
Language and Cultural Barriers:
Sex workers may also face language and cultural barriers when accessing healthcare. Many sex workers who do not speak the language of the country in which they work may face a severe challenge, making it difficult for them to communicate with healthcare providers . Language barriers can prevent sex workers from fully understanding their health status and treatment options, while cultural differences can lead to misunderstandings or inappropriate treatment . For sex workers, cultural norms can pose considerable obstacles, especially in societies where sex is taboo. This can make it difficult for sex workers to communicate with clients, negotiate their rates, or form positive relationships with non-sex workers .
Public Health Problems Encountered by Sex Workers:
Accessing healthcare treatments can be challenging for sex workers because of discrimination on the part of healthcare professionals, a lack of insurance, and a shortage of knowledgeable, understanding doctors. A marginalised minority, sex workers have a difficult time getting access to healthcare. The difficulty in getting healthcare for sex workers results from stigma, discrimination, criminalisation, and lack of resources . These problems could have a severe impact on their physical and mental well-being.
Elevated Risk of HIV and STIs due to Inconsistent Condom Use:
Female sex workers are more likely to contract HIV because of factors like limited condom availability in some settings, the potential for violence, the likelihood that condoms will be confiscated and used as evidence of unlawful conduct, the absence of labour rights and customers who would not use condoms, the high prevalence of HIV infection in the region, and the probability of violence . Therefore, the capacity to negotiate condom use can be reduced using drugs and alcohol, and HIV and hepatitis B and C can be spread using shared injecting equipment . Studies by Shannon et al. have also shown that the prevalence of HIV among sex workers is higher than that of the general population . This is due to a combination of factors, including inconsistent condom use, multiple sexual partners, drug and alcohol use, and exposure to violence . However, a recent assessment indicated considerable regional differences in the pooled prevalence of HIV among women who sold sex, ranging from 6.1% in Latin America to 10.9% in Eastern Europe and 36.9% in sub-Saharan Africa . Few studies have been conducted on other STIs, such as chlamydia and gonorrhoea, but many have examined the prevalence of HIV and syphilis infection among female sex workers . These infections can cause serious long-term health difficulties like pelvic inflammatory disease, ectopic pregnancy, and reproductive problems, raising the risk of HIV transmission. Additionally, compared to older women, younger women who sold sex had considerably higher incidences of gonorrhoea and chlamydia, according to a Chinese study by Chen, Yin, Liang, Wang, Jiang, Liu, and Wang .
Lack of Comprehensive Sexual and Reproductive Health Education, Information, and Poor Access to Healthcare Services:
Comprehensive sexual and reproductive health education is essential for sex workers, as it can help them make informed decisions about their sexual health and well-being. However, many sex workers do not receive this education due to various factors, such as social stigma, lack of resources, and limited access to information. Sex workers' health and well-being may be adversely affected by the lack of thorough sexual and health education and services. Without access to health education and services, sex workers can engage in risky sexual behaviours, such as unprotected sex, increasing their risk of contracting STIs and unprotected pregnancies. Therefore, this, in turn, can lead to long-term health complications.
Socas, Shoveller, Bean, Nguyen, Montaner and Shannon reported that most of the struggles discussed above, such as stigmatisation and criminalisation, contribute to poor access to healthcare services by sex workers . Negative attitudes of healthcare workers can make it difficult for sex workers to seek health, get tested, and be treated for STIs and HIV . This could lead to a high prevalence of AIDS and other STIs, such as chlamydia, gonorrhoea, and syphilis, as they may be hesitant to seek care due to fear of discrimination . Furthermore, many sex workers work in paying jobs without benefits or insurance, making it difficult to afford healthcare. They may also face discrimination when obtaining health insurance or financial assistance . Additionally, workers can pay for their healthcare out of pocket, which can be prohibitively expensive.
Mental Health Problems Resulting from Sex work:
These outcomes were related to alcohol and drug use, stress, and risk-related work in the sex industry . Most sex workers use drugs and alcohol as a coping mechanism. This causes sex workers to experience more stress as they fear being detained by authorities. On the other hand, sex workers are more likely to be kidnapped and have a greater probability of being raped by their clients, making them more depressed. Depression is a common mental health challenge facing sex workers . The stigma and discrimination associated with their work can cause hopelessness and despair. Lack of social support and isolation can also contribute to depression. Sex workers who experience depression may have difficulty finding motivation to work or may struggle to maintain relationships with clients or others in their personal lives . Anxiety is another common mental health challenge faced by sex workers. Sex workers may experience anxiety about their safety, health, and financial stability . Fear of arrest, violence, or discrimination can also contribute to anxiety. Sex workers who experience anxiety can feel on edge or constantly concerned, making it difficult to focus on their work and leading to avoidance behaviours . Posttraumatic stress disorder is a mental health condition that can develop after exposure to a stressful event. Sex workers are at greater risk of experiencing traumatic events, such as physical or sexual assault, police brutality, or other forms of violence. PTSD can result in nightmares, flashbacks, avoidance behaviours, and hyperarousal, which can interfere with the ability of sex workers to function and perform their work . Suicidal ideation is a severe mental health challenge that sex workers may face. The stigma and discrimination associated with their work and the lack of access to mental health care and support services can exacerbate feelings of hopelessness and despair. Sex workers who experience suicidal ideation may be at risk of self-harm or suicide, which can devastate their personal and professional lives .
DISCUSSION:
In a health and social setting, the study sought to analyse and examine the complicated lives of sex workers critically. This study found that sex workers typically struggle with significant health concerns due to several factors, including the stigma associated with their line of work, limited access to healthcare facilities, and the nature of the profession itself. One of the biggest challenges for sex workers seeking medical care is the stigma and discrimination they encounter. Many medical professionals hold incorrect beliefs about sex work and may be unwilling to treat patients or unintentionally do so. The results are in line with the previous studies. Moreover, the results of the study coincided with the findings of a study by as well as the precede-proceed model by Lawrence Green (1974) that social constructs like stigmatization and discrimination alter the quality of life for sex workers, consequently predisposing them to mental health problems and fear of seeking health care services .
Due to this, various health conditions, including STIs, HIV/AIDS, and mental health disorders, are not treated. The reviewed articles also mentioned limited access to healthcare services as a significant health challenge for sex workers. This can be attributed to several factors, including the fact that some nations consider sex work illegal or criminal, the fact that there are not enough resources available, or the places where sex work is done . As a result, access to preventive care and seeking medical attention when necessary is restricted for sex workers, which might worsen their health concerns. However, the nature of sex work itself carries certain health risks, including the possibility of physical harm, sexual assault, and contact with STDs . The survey also revealed that it can be challenging for sex workers to receive medical treatment during regular business hours due to the profession's long hours and unpredictable schedules . Overall, the difficulties that sex workers have access to healthcare highlight the need for policies and services that recognize this community’s particular difficulties and offer access to safe and supportive healthcare services to promote sex workers' health and well-being.
The general population stigmatises and discriminates against sex workers in the social setting. This is due to the widespread perception of sex work as normal or abnormal, which may lead to negative attitudes toward sex work and individuals who engage in it. The results include social marginalization as well as prejudice in employment and housing. The fact that sex work is prohibited only makes the social struggle that sex workers face worse . When the research was examined, it became clear from numerous studies that sex workers are subjected to harassment, violence, and arrest by law enforcement, further isolating them from society and reducing their ability to seek slegal or medical assistance . The challenges that sex workers face generally demonstrate the need for laws. The Precede-Proceed model proposes that to address the life complexities of sex workers in a social and health context, social constructs like stigmatization and discrimination among society, as well as the healthcare personnel, need to be addressed in order to improve the quality of life for sex workers. Increased incidence of STIs and HIV/AIDS among sex workers can be reduced by addressing the behavior of society and healthcare personnel towards sex workers .
RECOMMENDATIONS:
This comprehensive assessment offers crucial information on the difficulties faced by sex workers in South African communities in terms of healthcare and social challenges. To avoid healthcare and social battles among sex workers, the healthcare and social partners must actively work to eradicate this scourge from society. Addressing the social and medical issues faced by sex workers is a complicated issue that calls for multiple solutions and total commitment from a social and healthcare partners, including government and civil society. Evidence-based programs must be created to address the social and medical issues that sex workers encounter and to construct a theoretical framework. Additionally, there is a need for safety precautions, the beginning of campaigns to lessen stigma and violence, the provision of specialized healthcare services and sensitivity training for healthcare professionals, the development of social support networks, and the encouragement of research projects that consider the perspectives of sex workers.
LIMITATIONS:
The study was only concerned with the difficulties faced by sex workers in a medical and social setting. The included studies' quality and methodology differed, which could have introduced biases and weakened the validity of the results. Another issue is language bias, which resulted in the omission of critical viewpoints and studies by excluding papers published in languages other than English. The hidden and stigmatised nature of sex work can also lead to under reporting and restricted access to reliable data, affecting the assessment’s thoroughness. In the discussion, methodological limitations were not fully covered. The search methodology may have unintentionally left out a number of pertinent items, which may have impacted the thorough results. Notably, the lack of direct observation as a methodology may have prevented a more complex comprehension of the topic under study. (The author has his own study and views)
