Mental health problems among female sex workers in low- and middle-income countries: A systematic review and meta-analysis

Abstract

Background

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.

Method and findings

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.

Conclusions

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.

Abstract

Tara Beattie and co-workers assess the evidence on mental ill-health in female sex workers in low- and middle-income countries.

Author summary

Why was this study done?

• Understanding the prevalence of mental health problems, and key risk factors associated with poor mental health, is essential for building evidence-based prevention.

• To our knowledge, there has been no previous quantitative synthesis of the literature examining the prevalence of mental health problems among female sex workers (FSWs) in low- and middle-income countries (LMICs).

• This evidence is critical to inform evidence-based policymaking and intervention design and is timely given the growing interest in mental health globally.

What did the researchers do and find?

• We undertook a quantitative systematic review to estimate the prevalence of mental health problems and to estimate the magnitude of associations between mental health problems and sex workers’ experience of violence, harmful alcohol and drug use, condom use, and human immunodeficiency virus (HIV) and sexually transmitted infections (STIs).

• Meta-analyses across 31 studies with 18,524 FSWs in 17 LMICs suggest that mental health problems—including depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal thoughts and attempts—are highly prevalent among FSWs.

• Sex workers with a mental health problem were more likely to have experienced violence, to report harmful alcohol or drug use, to report inconsistent condom use with clients (but not regular partners), and to be HIV positive compared with sex workers who did not have a mental health problem (18 studies with 14,115 FSWs).

What do these findings mean?

• The quantitative evidence clearly demonstrates that mental health problems are an important burden of disease experienced by many FSWs in LMICs, with levels substantially greater than those experienced by women in the general population.

• As no study described a mental health intervention, evidence-based mental health interventions for FSWs are urgently required to address the current treatment gap. The prevention and treatment of key risk factors such as violence and harmful alcohol and drug use would also help improve the mental health of FSWs.

• Longitudinal research is needed in order to unpack pathways of causation. Future studies should use validated tools and consistent cut-offs and timeframes to enable more rigorous comparisons between studies.