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To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making.
We searched PubMed, CINAHL, and Embase databases using the search terms “sex work(ers),” “transactional sex,” “exchange sex,” “prostitution,” “contraception,” “contraceptive agents,” “birth control,” “female,” and “women.”
Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria.
Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell’s theory of gender and power as an analytic framework to further identify factors that limited reproductive agency.
Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion.
The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.
). Reproductive agency, or the ability of individuals to make their own decisions, is an important aspect of reproductive health. Given that sex workers experience heightened risk for UIP and its sequelae compounded by decreased reproductive agency for contraceptive use, it is important to investigate contraceptive choice and use among sex workers.
Sex workers experience heightened risk for unintended pregnancy and decreased reproductive agency, which underscores the need to investigate the choice and use of contraceptives.
Researchers who examined contraceptive use among sex workers in Russia (
) found that sex workers underused highly effective, female-controlled contraception. The most common contraception methods used by sex workers are partner-controlled methods, such as condoms and withdrawal (risk index of contraceptive failure 13% and 20%, respectively;
Exotic dancers (a subset of sex workers) are vulnerable to factors that limit reproductive agency around contraceptive decision making. Nearly half of exotic dancers reported that they engaged in trading sex for money or drugs (
). In qualitative interviews, exotic dancers described sex trade as commonplace and expected as a means to earn more money. Exotic dancers often cited substance use and financial pressure as rationales for entry into exotic dance. These same rationales also created vulnerability to financial pressure and reduced reproductive agency around reproductive decision making, such as pressure by partners for sex without condoms (
). Although research exists related to HIV risk with different partner types and condom use behaviors, little is known about the use of contraceptives and decision making among sex workers with different sex partner types (
Current tools to screen for the risk of UIP and theories that guide research on decision making about contraceptive use are often modeled in populations with reproductive agency over their decision making (
). Sex workers frequently experience factors that limit reproductive agency, including violence, substance use, and barriers to health care that may limit the applicability of current UIP risk screening tools and middle-range theories in this population (
). More information is needed to guide the development of tools to screen for UIP risk, contraceptive counseling guidelines, and theories for high-risk populations such as sex workers.
The aim of our review was to systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making. We selected the North American region rather than a global setting to limit intercountry differences and guide future specific research implications that might be influenced by regional differences among sex worker populations in a broader international context.
Guided by Connell’s theory of gender and power, we aimed to obtain a better understanding of the use of contraception among sex workers, with particular attention to factors that affect reproductive agency around contraceptive use and contraceptive decision making in populations at high risk for UIP (
). Knowledge gained from our review can help to guide future research, interventions, and the development of theory to improve contraceptive counseling and reduce UIP risk among high-risk, marginalized women.
Sex work does not operate in parallel to gendered power imbalance; rather, the two concepts are woven together because of the nature of trading sex for goods, money, or drugs (
defined three structures for understanding the relationships between men and women: the sexual division of labor (economic exposures and socioeconomic risk factors), the sexual division of power (physical and/or sexual violence and substance abuse), and cathexis (social norms and emotional attachments). An imbalance of power or agency favoring the male partner in any one of these three areas can posit negative reproductive health outcomes for the female partner (
). In July 2019, the research team and a reference librarian searched key electronic databases (PubMed, CINAHL Plus, and Embase) without date restrictions for relevant studies. The search was updated with the same search strategy in January 2020. The search strategy included a combination of MeSH terms and related synonyms, including sex work(ers), transactional sex, exchange sex, prostitution, contraception, contraceptive agents, birth control, female, and women. The terms were tailored to meet the specific formatting requirements of each database.
Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of study, (d) included a population assigned female sex at birth, (e) reported contraception outcomes for sex workers, and (f) were published in peer-reviewed journals. We excluded studies if they were published abstracts only or if results were not provided for sex workers. The population of interest for this review was sex workers; however, few women self-identify as sex workers. More commonly, individuals may endorse sex work behavior. Additionally, because of stigma and fear of persecution, sex workers are a hidden, difficult population to access in research. Therefore, sex workers are often included as secondary populations in studies of other high-risk groups, such as substance users. Researchers often report findings for sex workers as a secondary population of study in this case. For the purpose of our review, if results for sex workers or subsets of sex workers such as exotic dancers were included as a primary or secondary population, then those articles were considered to have met the population inclusion criterion.
), a reference manager tool, to screen articles for inclusion. We included quantitative and qualitative studies. Quantitative studies met inclusion if the outcome of the study included contraceptive use outcomes for the target population. For qualitative studies, our inclusion criterion required the report of study themes related to contraception.
We characterized the results of the included articles through consideration of population-specific factors affecting contraceptive use. Using Connell’s theory of gender and power as a theoretical foundation, we paid particular attention to factors that may limit reproductive agency, access, or contraceptive decision making for women at high risk for UIP. In Connell’s theory of gender and power, it is stipulated that gendered power imbalances can result in negative health implications for women (
). We assessed articles for Level of Evidence I through IV and Quality A through C. The included articles were all Level III evidence due to nonexperimental designs (observational and qualitative). We assessed study quality as an A (high quality) or B (good quality) for all included articles. A small, although adequate, sample size was our rationale for a B quality rating.
We retrieved 2,576 articles and removed 121 duplicates. We screened the titles and abstracts of 2,455 articles and excluded 2,304 because they did not meet the inclusion criteria. Two authors (J.L.Z. and A.P.B.) reviewed the full text of 151 articles. Seven articles met the inclusion criteria and were included (see Figure 1). The results of the included articles (two qualitative studies, one field report, and four observational studies) are included in Table 1.
Table 1A Summary of the Included Studies on Contraception and Sex Workers (SWs) in North America
Quality was assessed with Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines (Dang & Dearholt, 2017). Evidence levels ranged from I to IV based on study design: Level I, experimental studies and randomized control trials; Level II, quasiexperimental; Level III, nonexperimental studies and qualitative studies; and Level IV, expert opinions, consensus panels, and clinical practice guidelines. Quality was ranked as A through C: A, high-quality studies that had sufficient sample sizes, adequate control of confounding, definitive conclusions, and comprehensive literature reviews; B, good-quality studies that had sufficient sample sizes, some control, and fairly definitive conclusions; and C, low-quality or major flaws and little evidence with inconsistent results.
Tier 1 methods include implants, intrauterine devices, and sterilization (tubal ligation and vasectomy). Tier 2 methods include injectables, pills, patch, or the ring. Tier 3 methods include male or female condoms, sponge, withdrawal, fertility awareness, or spermicides.
). Evidence levels ranged from I to IV based on study design: Level I, experimental studies and randomized control trials; Level II, quasiexperimental; Level III, nonexperimental studies and qualitative studies; and Level IV, expert opinions, consensus panels, and clinical practice guidelines. Quality was ranked as A through C: A, high-quality studies that had sufficient sample sizes, adequate control of confounding, definitive conclusions, and comprehensive literature reviews; B, good-quality studies that had sufficient sample sizes, some control, and fairly definitive conclusions; and C, low-quality or major flaws and little evidence with inconsistent results.
b Tier 1 methods include implants, intrauterine devices, and sterilization (tubal ligation and vasectomy). Tier 2 methods include injectables, pills, patch, or the ring. Tier 3 methods include male or female condoms, sponge, withdrawal, fertility awareness, or spermicides.
Of the seven studies we included, five were conducted in the United States, one in Canada, and one at the Mexico–Guatemala border. The five quantitative studies were observational in design. Sample sizes ranged from 26 to 1,277 participants in quantitative studies and 23 to 31 participants in qualitative studies. In two studies, researchers addressed stigma and contraceptive method use (
). All researchers addressed a component of health care access such as insurance, co-location of care services at the workplace, and/or use of reproductive health care clinics. Two articles addressed pregnancy intention among the participants (
We categorized contraceptive methods using a three-tier system to evaluate contraceptive efficacy (see Table 1). Efficacy is determined by the rates of contraceptive failure with ideal use; efficacy in the prevention of pregnancy is greatest for Tier 1 methods and lower for each subsequent tier (
). IUDs, sterilization (tubal ligation), and implants are examples of Tier 1 methods. Tier 2 methods include oral contraceptive pills, vaginal rings, and hormone injections. Condoms, a Tier 3 method, were the most common method used by sex workers across studies.
Researchers in all seven studies highlighted the lack of contraceptive use and unmet contraceptive needs among sex workers (
). Sex workers commonly use no contraceptive method or Tier 3 contraceptive methods. In one study of transgender male patients (assigned female sex at birth) at a clinic for sex workers, 62% of participants at risk for pregnancy used condoms, and 38% used no contraceptive method (
). Although 85% of the sample was at risk for pregnancy (intact uterus and engaged in receptive vaginal intercourse with a cis-male partner), only one participant used a Tier 1 method (partner vasectomy). Similarly, in a Canadian study of venue-based (massage parlors, microbrothels, bars, hotels, and saunas) sex workers, nearly 64% of sex workers used condoms for contraception (
When comparing women with histories of sex work to those without, researchers found that sex workers were less likely, albeit nonsignificantly, to present to clinics for contraception (adjusted relative risk [aRR] = 0.91, 95% confidence interval [CI] [0.70, 1.18]) and more likely to report multiple visits for emergency contraception (aRR = 1.21, 95% CI [0.69, 2.12];
). Sex workers also experienced increased rates of UIPs (aRR = 1.27, 95% CI [1.09, 1.48]) and two or more abortions (aRR = 1.63, 95% CI [1.19, 2.23]), which further highlights the unmet contraceptive needs among this group.
reported descriptive statistics of reproductive health services provided on a needle exchange mobile van located in a “red-light” (ubiquity of sex work) district in Baltimore City. Researchers found that 75% of women had unmet reproductive health needs, which were defined as not currently receiving reproductive health care services. Of the 220 participants who accessed the mobile van during the study, 62.7% received contraception in the form of Depo-Provera injections (Pfizer Inc., New York, NY) or oral contraceptives. Among new exotic dancers (
), only 25% of women used dual-method contraception by combining condoms and a high-efficacy Tier 1 or Tier 2 method. Of the women who used condoms as a single or dual method of contraception, only 14% used them consistently.
). Participants identified stigmatization related to sex work as a barrier for engagement with reproductive health care providers for the provision of nonbarrier contraception. Participants expressed a lack of knowledge about other contraceptive methods and described learning about pregnancy prevention from other sex workers or in a health care setting after a pregnancy. Women learned about condoms most often as a means to prevent HIV and sexually transmitted infections but rarely received education or information about contraception for the prevention of UIPs.
For sex workers using substances, drug use was a competing priority to the use of contraceptives (
). Although these participants reported that they received prescriptions for Tier 2 methods in the past, at the time of the study, few continued to use them. Participants described that active drug use took precedence over reproductive health visits aside from giving birth or obtaining an abortion and over the use of prescribed contraceptive methods.
Access to Health Care
All seven of the reviewed articles included components of health care access affecting contraceptive use, such as insurance, having a health care provider, workplace health care, or use of family planning clinics/services. Addressing health care access is key when addressing contraception because although condoms (Tier 3) are available without a prescription or doctor visit, sterilization, IUDs (Tier 1), and highly effective hormonal methods of contraception (Tier 2) require access to medical care (clinician and/or pharmacist). Health care systems, payment, and insurance vary across North American countries included in this review, but the provision of contraception and reproductive health services beyond barrier contraception requires some contact with health care providers (clinicians and/or pharmacists) in all countries.
Insurance and payment concerns resulted in delayed or reduced access to reproductive health services for sex workers at the Mexico-Guatemala border (
). Migrant sex workers described that they delayed reproductive health services until they returned to their home countries because of the lack of health care coverage in their resident countries. Accessing care in resident countries was driven by necessity versus prioritization of prevention services. Therefore, women delayed in obtaining contraception because of financial and insurance constraints.
For sex workers in the United States, we did not find a clear correlation between having health insurance and the use of reproductive services. In studies of exotic dancers in Baltimore City, MD, researchers found that having health insurance or care coordination services did not result in successfully meeting reproductive needs (
). Researchers reported that despite same- or next-day appointments, telephone reminders, incentives, and care coordination services, there was limited follow-up by participants for reproductive health services. Although women did not follow up with outside appointments, they did access care at the mobile van positioned near their workplaces.
reported 220 visits from 2009 to 2011; 63% of those visits were to obtain contraception, and of the participants who received contraception, 64% received Depo-Provera injections, and 33% received oral contraceptives. Almost half of the women who received a first Depo-Provera injection returned for a second injection. Researcher efforts to refer women to full reproductive health services in local clinics were futile, but women were receptive to immediate mobile van services for contraception near their workplaces.
For sex workers working in a venue-based setting in Canada, health care access at the workplace improved condom use for contraception (
). Researchers followed a longitudinal cohort of venue-based sex workers and found that women who scored higher on the access to sexual and reproductive health services portion of the validated Safer Indoor Work Environment Scale were significantly more likely to use condoms to prevent pregnancy (adjusted odds ratio = 1.02, 95% CI [1.01, 1.04], p ≤ .001). Co-locating reproductive health services and women’s workplaces resulted in improved contraceptive use to prevent UIPs.
Stigma, lack of access to health care, and factors that increase vulnerability in sex workers all pose barriers to contraceptive use.
Sex work is highly stigmatized, which results in discrimination and social isolation for those who engage in it. Fear of stigma can result in hesitancy to disclose highly personal information, such as sex work behavior, to health care providers (
). Migrant women felt dually stigmatized by their status as migrants and their sex worker status. Women expressed in interviews that they were less likely to access reproductive health services because of perceived stigma (
Sex workers have sexual networks that include nonpaying intimate partners and paying clients who pay for sex with money, drugs, or goods. Researchers who examined HIV risk identified that women engage in different behaviors if a partner is “casual” versus a more committed “main” partner. It is not well understood if similar decision making applies to contraception in the context of different partner types (
). Women reported not using contraception with nonpaying partners to demonstrate closeness to the partner, to differentiate that relationship from paying partners, or because their partners refused to use condoms. Contraceptive decision making among study participants varied based on the partner type.
Sex workers, like many women, may desire pregnancy during their lifetimes (
), and the desire to become pregnant influences a woman’s choice to use a contraceptive method. However, this unique population experiences a mix of paying and nonpaying partners. Previous research among sex workers showed that pregnancy intention can vary based on partner type; participants wanted pregnancy with intimate partners but avoided it with paying clients (
). Neither of these studies addressed whether this desire varied by partner type or how intentions affected contraceptive decision making. Comprehensive reproductive health care necessitates the consideration of different partner types and their implications for reproductive planning.
Substance use is common among sex workers and was discussed in three of the reviewed studies (
). Contraceptive decision making can be influenced or impaired by substance use, so understanding its relationship to contraceptive use in this population of women with high rates of substance use and UIP is important. Investigators in two studies found high rates of alcohol use disorder (73%;
). However, women with access to substance use harm reduction services located at their work venue reported significantly greater odds of the use of condoms for contraception (adjusted odds ratio = 1.13, 95% CI [1.01, 1.28], p = .042). The provision of methods to reduce harm from substance use had direct effects on improving reproductive health outcomes.
A relationship between substance use and contraceptive decision making emerged from qualitative interviews of women who were sex workers and used substances (
). Women reported that their primary focus was on obtaining drugs. Reproductive health was secondary to drug use, which often resulted in failure to take or refill contraceptive methods or follow up for reproductive health visits.
IPV and Condom Coercion
Violence by clients and/or intimate partners is experienced by more than half of sex workers (
). Women who experience physical/sexual violence or condom coercion may not have full control over their reproductive decisions, particularly when using partner-dependent contraceptive methods, such as condoms.
In previous studies of violence and contraceptive method use, researchers reported mixed results; condom use is often reduced in violent relationships (
found sex workers were three to four times more likely to report a history of unwanted sex. In qualitative interviews, women reported feeling financial pressure to not use condoms by clients because of greater payments for condomless sex (
). The authors concluded that improved safety facilitated women’s ability to advocate for themselves and limited client’s coercion over condom negotiation.
Condoms were overwhelmingly the most common contraceptive method used by sex workers across studies. Although condom use is critical in the prevention of HIV and sexually transmitted infections, for contraceptive purposes, failure to use condoms and the low uptake of dual contraception among sex workers create significant vulnerability to UIP. Although in general the use of Tier 1 and Tier 2 efficacy contraceptive methods was low by study participants, researchers identified barriers and facilitators to the use of these methods.
For women in the Mexico–Guatemala region, financial insecurity, migrant status, and insurance coverage played a significant role in their abilities to access reproductive care. Sex workers in the United States and Canada were largely insured, but this did not facilitate accessing reproductive care. Rather, the co-location of care services where women worked facilitated access to reproductive health care.
Perceived stigma regarding sex work and an overall lack of knowledge about contraception were barriers to accessing care for women in the Mexico–Guatemala region. Women in the United States often reported prior use of higher efficacy methods, which infers knowledge and access to those methods, but discontinued methods because of factors that limit reproductive agency, such as substance use.
Sex workers have the right to determine the number and timing of pregnancies they desire (
). Pregnancy intentions among sex workers were high, indicating that many women are planning for pregnancy now or in the future. Previous research has shown that sex workers who desire pregnancy will often rely on Tier 3 contraceptive methods, such as condoms, to allow for selective use with partners with whom pregnancy is desired and undesired (
). None of the researchers discussed how women navigate these pregnancy intentions in the context of sex work and partner concurrency or if preference for pregnancy with paying clients versus intimate partners drove contraceptive decision making. More research is needed to understand contraceptive decision making in the context of different types of sexual partnerships (
IPV, condom coercion, and substance use were common among sex workers in the included studies. Women reported being unable to execute their reproductive desires because of pressure for unprotected sex and forced sex by partners. Adherence to methods was diminished by a focus on substance use versus medical follow-up visits.
Nurses are poised to fuse clinical practice, research, and policy to improve reproductive health care services for marginalized women such as sex workers.
Implications for Practice and Research
Little attention has been paid to the reproductive health needs of sex workers. Sex workers experience high rates of factors that limit reproductive agency around reproductive decision making, such as violence and substance use. Awareness of the relationship of violence, substance use, and contraception by clinicians who care for vulnerable populations can guide contraceptive counseling with women. The
recommended periodic screening of reproductive-aged women for experiences of IPV and reproductive and sexual coercion. Screening for IPV at reproductive health visits can assist in the identification of women experiencing limitations in reproductive agency related to violence and guide contraceptive counseling and referrals for support services.
Women, such as sex workers, who identify limitations in reproductive agency should be counseled regarding use of contraceptive methods less susceptible to partner influence, such as IUDs or injectable contraceptives (
). Clinicians who provide contraceptive counseling to sex workers with substance use disorder must consider the potential challenges some women may face with adherence to methods that require refills or repeated health care visits. Among sex workers who desire pregnancy, careful assessment of pregnancy intentions and partners’ influences are necessary because intentions may vary by partner type. For women desiring pregnancy, nonjudgmental, supportive prenatal counseling is necessary (
Sex workers, as a population, are difficult to sample due to stigma and legal implications around sex work. As a result, researchers often focus on other high-risk groups and include sex workers as a secondary study population. The benefit of this approach is the ability to capture critical data about a difficult to access population. The drawback of this approach is that it results in small secondary samples that are not stratified by contraception outcomes. Smaller secondary samples, if stratified, may lack statistical power to identify significant findings. Future research with larger sample sizes focused on a primary sample of sex workers is necessary.
Much current public health research involving sex workers is focused on disease prevention (
). Research with a focus on holistic provision of integrated reproductive care and harm reduction services should be explored to improve health outcomes for vulnerable women.
Nurses are on the frontline of care for vulnerable populations. There is a need for the development of middle-range nursing theories to address contraceptive decision making in women with limited reproductive agency around reproductive decision making. Contraceptive studies grounded in theories with a focus on an individual’s ability to control reproductive decision making are ill-suited for populations of women who experience gendered power imbalances, which might limit their contraceptive decision making. In addition to theory development, nurses are poised to fuse clinical practice, research, and policy to improve health care system integration of reproductive health care services with the goal of holistic care for marginalized women.
Research in sex worker populations in North America is sparse, thus limiting the pool of articles for inclusion in our review. The designs of the included studies were observational or qualitative in nature, therefore describing relationships of interest in the study sample but limiting generalizability. The sample size in the included quantitative studies ranged from 26 to 1,277 participants. The ability to generalize the findings of quantitative studies with smaller sample sizes was limited (
Sex workers underuse highly effective contraception and instead rely on condoms to prevent pregnancy. Factors that limit reproductive agency, such as violence, stigma, and substance use, influence these women’s ability to control reproductive decision making. The integration of health care and harm reduction services where women work improves contraceptive use. There is a need to understand more about the contraceptive decision-making process of this population in the context of different sexual partnerships and pregnancy intentions. A focus beyond HIV and disease prevention is necessary to achieve improved reproductive health outcomes in vulnerable women and prevent UIP.
American College of Obstetricians and Gynecologists
ACOG committee opinion no. 554: Reproductive and sexual coercion.