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Systematic Review of Contraceptive Use Among Sex Workers in North America

Published:September 12, 2020DOI:https://doi.org/10.1016/j.jogn.2020.08.002

      Abstract

      Objective

      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.

      Data Sources

      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.”

      Study Selection

      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.

      Data Extraction

      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.

      Data Synthesis

      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.

      Conclusion

      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.

      Key words

      Despite advances in the efficacy of contraceptives, sex workers experience a disproportionate number of unintended pregnancies (UIPs) compared with women who do not sell sex (
      • Lilleston P.S.
      • Reuben J.
      • Sherman S.G.
      Exotic dance in Baltimore: From entry to STI/HIV risk.
      ). Sex workers at risk for UIP include women assigned female sex at birth who exchange sex for food, drugs, money, or goods and subsets of sex workers including exotic dancers (
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). The termination of a UIP occurs at least once for 50% to 65% of sex workers and signals unmet reproductive health needs (
      • Schwartz S.R.
      • Baral S.
      Fertility-related research needs among women at the margins.
      ;
      • Zhang X.-D.
      • Kennedy E.
      • Temmerman M.
      • Li Y.
      • Zhang W.-H.
      • Luchters S.
      High rates of abortion and low levels of contraceptive use among adolescent female sex workers in Kunming, China: A cross-sectional analysis.
      ). Among sex workers, risk factors such as intimate partner violence (IPV), condom coercion (
      • Ulibarri M.D.
      • Salazar M.
      • Syvertsen J.L.
      • Bazzi A.R.
      • Rangel M.G.
      • Orozco H.S.
      • Strathdee S.A.
      Intimate partner violence among female sex workers and their noncommercial male partners in Mexico: A mixed-methods study.
      ), increased number of sexual encounters, poverty, stigma, and limited health care access all raise the risk for UIPs (
      • Schwartz S.R.
      • Baral S.
      Fertility-related research needs among women at the margins.
      ). These common risk factors can also influence sex workers’ decision making around contraceptive use (
      • Schwartz S.R.
      • Baral S.
      Fertility-related research needs among women at the margins.
      ;
      • Tomko C.
      • Allen S.T.
      • Glick J.
      • Sherman S.G.
      • Park J.N.
      • Galai N.
      • Footer K.H.A.
      Awareness and interest in HIV pre-exposure prophylaxis among street-based female sex workers: Results from a US context.
      ;
      • Ulibarri M.D.
      • Salazar M.
      • Syvertsen J.L.
      • Bazzi A.R.
      • Rangel M.G.
      • Orozco H.S.
      • Strathdee S.A.
      Intimate partner violence among female sex workers and their noncommercial male partners in Mexico: A mixed-methods study.
      ). UIP is associated with adverse maternal health outcomes, such as depression and an increased risk to experience violence (
      • Bahk J.
      • Yun S.C.
      • Kim Y.M.
      • Khang K.H.
      Impact of unintended pregnancy on maternal mental health: A causal analysis using follow up data of the Panel Study on Korean Children (PSKC).
      ). 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 (
      • Martin C.E.
      • Wirtz A.L.
      • Mogilniy V.
      • Peryshkina A.
      • Beyrer C.
      • Decker M.R.
      Contraceptive use among female sex workers in three Russian cities.
      ) and Afghanistan (
      • Todd C.S.
      • Nasir A.
      • Raza Stanekzai M.
      • Scott P.T.
      • Strathdee S.A.
      • Botros B.A.
      • Tjaden J.
      Contraceptive utilization and pregnancy termination among female sex workers in Afghanistan.
      ) 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;
      • Duff P.
      • Evans J.L.
      • Stein E.S.
      • Page K.
      • Maher L.
      Young Women’s Health Study Collaborative
      High pregnancy incidence and low contraceptive use among a prospective cohort of female entertainment and sex workers in Phnom Penh, Cambodia.
      ). Fewer sex workers use female-controlled methods such as intrauterine devices (IUDs), implants, hormonal methods, and sterilization, which all carry lower failure rates (1% or less;
      • Hatcher R.A.
      • Trussell J.
      • Cwiak C.
      • Cason P.
      • Policar M.S.
      • Edelman A.
      • Kowal D.
      Contraceptive technology (21st ed.).
      ). The underuse of female-controlled contraception increases the likelihood of UIPs in this population of women (
      • Bautista C.T.
      • Mejía A.
      • Leal L.
      • Ayala C.
      • Sanchez J.L.
      • Montano S.M.
      Prevalence of lifetime abortion and methods of contraception among female sex workers in Bogota, Colombia.
      ;
      • Decker M.R.
      • Yam E.A.
      • Wirtz A.L.
      • Baral S.D.
      • Peryshkina A.
      • Mogilnyi V.
      • Beyrer C.
      Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia.
      ;
      • Yam E.A.
      • Tinajeros F.
      • Revollo R.
      • Richmond K.
      • Kerrigan D.L.
      • Garcia S.G.
      Contraception and condom use among Bolivian female sex workers: Relationship-specific associations between disease prevention and family planning behaviors.
      ).
      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 (
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). 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 (
      • Lilleston P.S.
      • Reuben J.
      • Sherman S.G.
      Exotic dance in Baltimore: From entry to STI/HIV risk.
      ).
      Sex workers may have different types of sexual partners including clients and nonpaying romantic partners (
      • Park J.N.
      • Footer K.H.A.
      • Decker M.R.
      • Tomko C.
      • Allen S.T.
      • Galai N.
      • Sherman S.G.
      Interpersonal and structural factors associated with receptive syringe-sharing among a prospective cohort of female sex workers who inject drugs.
      ). Researchers who studied the prevention of HIV found that sex workers used condoms more consistently with clients versus nonpaying romantic partners (
      • Argento E.
      • Shannon K.
      • Nguyen P.
      • Dobrer S.
      • Chettiar J.
      • Deering K.N.
      The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners.
      ;
      • Tracas A.
      • Bazzi A.R.
      • Artamonova I.
      • Rangel M.G.
      • Staines H.
      • Ulibarri M.D.
      Changes in condom use over time among female sex workers and their male noncommercial partners and clients.
      ). 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 (
      • Yam E.A.
      • Okal J.
      • Musyoki H.
      • Muraguri N.
      • Tun W.
      • Sheehy M.
      • Geibel S.
      Association between condom use and use of other contraceptive methods among female sex workers in Swaziland: A relationship-level analysis of condom and contraceptive use.
      ).
      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 (
      • Baldwin S.
      • Singhal R.
      • Allen D.S.
      Optimizing care for women of reproductive age with one key question.
      ;
      • Morof D.
      • Steinauer J.
      • Haider S.
      • Liu S.
      • Darney P.
      • Barrett G.
      Evaluation of the London Measure of Unplanned Pregnancy in a United States population of women.
      ). 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 (
      • Stephenson R.
      • Bartel D.
      • Rubardt M.
      Constructs of power and equity and their association with contraceptive use among men and women in rural Ethiopia and Kenya.
      ). 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.

      Theoretical Framework

      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 (
      • Connell R.
      Gender and power.
      ). 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 (
      • Thaller J.
      • Cimino A.N.
      The girl is mine: Reframing intimate partner violence and sex work as intersectional spaces of gender-based violence.
      ). This relationship between gendered power imbalance and reproductive decision making is likewise connected for sex workers. In the theory of gender and power,
      • Connell R.
      Gender and power.
      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 (
      • Connell R.
      Gender and power.
      ).

      Methods

       Data Sources

      We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct our review (see Figure 1;
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
      ). 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.
      Figure thumbnail gr1
      Figure 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) literature search strategy.

       Study Selection

      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.
      We used RefWorks software (
      ProQuest RefWorks
      RefWorks Web Based Bibliographic Management Software (Version 2.0) [Computer software]. ProQuest LLC.
      ), 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.

       Data Extraction

      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 (
      • Connell R.
      Gender and power.
      ).

       Assessment of Methodological Quality

      Two authors (J.L.Z. and A.P.B.) assessed the included articles for quality using Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines and agreed on quality assessments (
      • Dang D.
      • Dearholt S.
      ). 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.

      Results

      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
      Author(s) and CountryDesign, Total, and SW Sample SizeSex Work DefinitionPopulationStudy AimsQuality Assessment
      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.
      Current Contraceptives Used and Method Efficacy
      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.
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • Nova C.
      • O’Shea A.
      • Obedin-Maliver J.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      , United States
      Cross-sectional, N = 26, SW = 16Past or current sex workTransgender male patients at clinic for SWsIdentify unmet contraceptive needs, pregnancy intentions, # at risk for pregnancy (intact uterus)III BCondoms (Tier 3); partner vasectomy

      (Tier 1)
      • Decker M.R.
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Levenson R.R.
      • Waldman J.
      • Silverman J.G.
      Sex trade among young women attending family-planning clinics in Northern California.
      , United States
      Cross-sectional, N = 1,277, SW = 103Ever trade sex or sexual acts in exchange for food, drugs, money, or shelterFamily planning clinic patientsEvaluate prevalence of sex work in family planning clinics and identify sexual and reproductive health needs in SWsIII ACondoms (Tier 3)
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      , United States
      Qualitative, N = 26, SW = 23Trade sex for drugs or moneySubstance using womenExplore contraceptive risk takingIII ASterilization (Tier 1); condoms

      (Tier 3)
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      , Canada
      Longitudinal cohort, N = 588, SW = 588Sex for money within the past 30 days in street, indoor, or online venueSWs in indoor venuesLongitudinally assess association between social, policy, and physical features of indoor venues and condom use for pregnancy preventionIII ACondoms: 63.6% (Tier 3); other method info collected every 6 months, results not reported
      • Moore E.M.
      • Han J.
      • Serio-Chapman C.E.
      • Mobley C.
      • Watson C.
      • Terplan M.
      Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services prioritizing female exotic dancers.
      , United States
      Field report, N = 126, SW = 126Exotic dancersExotic dancers in Baltimore CityDescribe health partnerships' provisions of reproductive health services and needle exchange in mobile vanIII BNew prescriptions from study: Depo injection: 62.7% (Tier 2; 46% returned for second shot); pill: 33% (Tier 2); condoms: 100% (Tier 3)
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      , Mexico-Guatemala border
      Qualitative, N = 31, SW = 31Exchange sex for money in previous 1 monthInternational migrantsExplore experiences with unmet needs and access sexual and reproductive healthIII APill (Tier 2); condoms (Tier 3)
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      , United States
      Cross-sectional, N = 117, SW = 117Exotic dancer in club for 12 months or lessExotic dancers in Baltimore CityIdentify reproductive health needs and contraceptive useIII BDual method: 26%; sterilization: 5%; IUD: 20%; implant: 7% (Tier 1); injection: 39% (Tier 2); condoms: 100% use, 14% use consistently (Tier 3)
      Note. IUD = intrauterine device.
      a Quality was assessed with Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines (
      • Dang D.
      • Dearholt S.
      ). 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 (
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). Researchers in four articles addressed the roles of different types of sexual partners (clients and nonpaying romantic partners) and contraceptive use (
      • Decker M.R.
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Levenson R.R.
      • Waldman J.
      • Silverman J.G.
      Sex trade among young women attending family-planning clinics in Northern California.
      ;
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ;
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). 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 (
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • Nova C.
      • O’Shea A.
      • Obedin-Maliver J.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      ;
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). The relationship between substance use by sex workers and contraception was examined in three of the seven included articles (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ;
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). Researchers in four studies examined interpersonal violence in the form of IPV (physical or sexual violence) and/or in relation to contraceptive use (a partner’s refusal or removal of condoms;
      • Decker M.R.
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Levenson R.R.
      • Waldman J.
      • Silverman J.G.
      Sex trade among young women attending family-planning clinics in Northern California.
      ;
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ;
      • Duff P.
      • Shoveller J.
      • Feng C.
      • Ogilvie G.
      • Montaner J.
      • Shannon K.
      Pregnancy intentions among female sex workers: Recognizing their rights and wants as mothers.
      ;
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ).

       Contraception Use and Need

      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 (
      • Hatcher R.A.
      • Trussell J.
      • Cwiak C.
      • Cason P.
      • Policar M.S.
      • Edelman A.
      • Kowal D.
      Contraceptive technology (21st ed.).
      ). 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 (
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • Nova C.
      • O’Shea A.
      • Obedin-Maliver J.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      ;
      • Decker M.R.
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Levenson R.R.
      • Waldman J.
      • Silverman J.G.
      Sex trade among young women attending family-planning clinics in Northern California.
      ;
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ;
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ;
      • Moore E.M.
      • Han J.
      • Serio-Chapman C.E.
      • Mobley C.
      • Watson C.
      • Terplan M.
      Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services prioritizing female exotic dancers.
      ;
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). 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 (
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • Nova C.
      • O’Shea A.
      • Obedin-Maliver J.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      ). 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 (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ).
      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];
      • Decker M.R.
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Levenson R.R.
      • Waldman J.
      • Silverman J.G.
      Sex trade among young women attending family-planning clinics in Northern California.
      ). 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.
      In a study of exotic dancers,
      • Moore E.M.
      • Han J.
      • Serio-Chapman C.E.
      • Mobley C.
      • Watson C.
      • Terplan M.
      Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services prioritizing female exotic dancers.
      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 (
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ), 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.
      The authors of two qualitative studies (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ;
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ) described barriers to the use of highly efficacious contraceptive methods. Among migrant sex workers at the Mexico–Guatemala border, condoms were the most commonly used method (
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ). 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 (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ). 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 (
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant 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 (
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). Although 83% of the participants had health insurance, 82% were at risk for pregnancy and had current contraceptive needs.
      Investigators examined the effectiveness of a program to provide co-located reproductive health services and needle exchange in a red-light area with several exotic dance clubs in Baltimore City (
      • Moore E.M.
      • Han J.
      • Serio-Chapman C.E.
      • Mobley C.
      • Watson C.
      • Terplan M.
      Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services prioritizing female exotic dancers.
      ). 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.
      • Moore E.M.
      • Han J.
      • Serio-Chapman C.E.
      • Mobley C.
      • Watson C.
      • Terplan M.
      Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services prioritizing female exotic dancers.
      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 (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). 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.

       Stigma

      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 (
      • Liu S.H.
      • Srikrishnan A.K.
      • Zelaya C.E.
      • Solomon S.
      • Celentano D.D.
      • Sherman S.G.
      Measuring perceived stigma in female sex workers in Chennai, India.
      ). Stigma was addressed in two articles as a barrier to accessing reproductive health care (
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). Nearly half of exotic dancers reported feeling stigmatized (
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). 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 (
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ).

       Complexity of Partner Types

      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 (
      • Ochako R.
      • Kimetu S.
      • Askew I.
      • Temmerman M.
      Female sex workers experiences of using contraceptive methods: A qualitative study in Kenya.
      ).
      In qualitative interviews with women who used substances, sex workers used contraception differently with paying clients and intimate partners (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ). 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.

       Pregnancy Intention

      Sex workers, like many women, may desire pregnancy during their lifetimes (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ), 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 (
      • Farel C.E.
      • Parker S.D.
      • Muessig K.E.
      • Grodensky C.A.
      • Jones C.
      • Golin C.E.
      • Wohl D.A.
      Sexuality, sexual practices, and HIV risk among incarcerated African-American women in North Carolina.
      ).
      Two of the reviewed studies addressed pregnancy intention. In venue-based sex workers, 45.5% of participants desired pregnancy in the future (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). In transgender male sex workers, 6% desired pregnancy (
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • Nova C.
      • O’Shea A.
      • Obedin-Maliver J.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      ). 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

      Substance use is common among sex workers and was discussed in three of the reviewed studies (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ;
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ). 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%;
      • Terplan M.
      • Martin C.E.
      • Nail J.
      • Sherman S.G.
      Contraceptive utilization among new exotic dancers: A cross-sectional study.
      ) and intravenous drugs (38%;
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). 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 (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ). 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 (
      • Ulibarri M.D.
      • Salazar M.
      • Syvertsen J.L.
      • Bazzi A.R.
      • Rangel M.G.
      • Orozco H.S.
      • Strathdee S.A.
      Intimate partner violence among female sex workers and their noncommercial male partners in Mexico: A mixed-methods study.
      ) versus one third of women in the general population (
      • Smith S.G.
      • Zhang X.
      • Basile K.C.
      • Merrick M.T.
      • Wang J.
      • Kresnow M.
      • Chen J.
      The National Intimate Partner and Sexual Violence Survey (NISVS): 2015 data brief—Updated release.
      ). IPV and condom coercion are associated with a greater risk of UIP (
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Decker M.R.
      • Anderson H.
      • Silverman J.G.
      Recent reproductive coercion and unintended pregnancy among female family planning clients.
      ). 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 (
      • Bergmann J.N.
      • Stockman J.K.
      How does intimate partner violence affect condom and oral contraceptive use in the United States? A systematic review of the literature.
      ), but there is an increased covert use of female-controlled contraceptive methods such as IUDs, implants, and injections (
      • Salazar M.
      • Valladares E.
      • Hogberg U.
      Questions about intimate partner violence should be part of contraceptive counselling: Findings from a community-based longitudinal study in Nicaragua.
      ). Women covertly attempt to reduce the risk of UIP in the presence of physical/sexual violence and condom coercion.
      Investigators in four reviewed studies discussed IPV, sexual coercion, or condom coercion related to contraception in sex workers.
      • Decker M.R.
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Levenson R.R.
      • Waldman J.
      • Silverman J.G.
      Sex trade among young women attending family-planning clinics in Northern California.
      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 (
      • Drescher-Burke K.
      Contraceptive risk-taking among substance-using women.
      ). Women reported that intimate partners refused condoms, contrary to their wishes (
      • Rocha-Jimenez T.
      • Morales-Miranda S.
      • Fernandez-Casanueva C.
      • Brouwer K.C.
      • Goldenberg S.M.
      • Rocha-Jiménez T.
      • Goldenberg S.M.
      Stigma and the unmet sexual and reproductive health needs among international migrant sex workers at the Mexico-Guatemala border.
      ). Sex workers who reported higher physical safety scores in the workplace had increased odds of using condoms for contraception (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). The authors concluded that improved safety facilitated women’s ability to advocate for themselves and limited client’s coercion over condom negotiation.

      Discussion

      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 (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). 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 (
      • Long J.E.
      • Waruguru G.
      • Yuhas K.
      • Wilson K.S.
      • Masese L.N.
      • Wanje G.
      • Scott McClelland R.
      Prevalence and predictors of unmet contraceptive need in HIV-positive female sex workers in Mombasa, Kenya.
      ). 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 (
      • Upadhyay U.D.
      • Raifman S.
      • Raine-Bennett T.
      Effects of relationship context on contraceptive use among young women.
      ).
      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
      American College of Obstetricians and Gynecologists
      ACOG committee opinion no. 554: Reproductive and sexual coercion.
      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 (
      • Miller E.
      • McCauley H.L.
      • Tancredi D.J.
      • Decker M.R.
      • Anderson H.
      • Silverman J.G.
      Recent reproductive coercion and unintended pregnancy among female family planning clients.
      ). 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 (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ).
      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 (
      • Park J.N.
      • Footer K.H.A.
      • Decker M.R.
      • Tomko C.
      • Allen S.T.
      • Galai N.
      • Sherman S.G.
      Interpersonal and structural factors associated with receptive syringe-sharing among a prospective cohort of female sex workers who inject drugs.
      ;
      • Schwartz S.R.
      • Baral S.
      Fertility-related research needs among women at the margins.
      ;
      • Tomko C.
      • Allen S.T.
      • Glick J.
      • Sherman S.G.
      • Park J.N.
      • Galai N.
      • Footer K.H.A.
      Awareness and interest in HIV pre-exposure prophylaxis among street-based female sex workers: Results from a US context.
      ). Many sex workers have complex lives with high psychosocial vulnerabilities to HIV and UIP, but they also have reproductive desires similar to women in the general population (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ). Co-location of reproductive and harm reduction care where women work resulted in improved reproductive health outcomes (
      • Duff P.
      • Shoveller J.
      • Dobrer S.
      • Ogilvie G.
      • Montaner J.
      • Chettiar J.
      • Shannon K.
      The relationship between social, policy and physical venue features and social cohesion on condom use for pregnancy prevention among sex workers: A safer indoor work environment scale.
      ;
      • Moore E.M.
      • Han J.
      • Serio-Chapman C.E.
      • Mobley C.
      • Watson C.
      • Terplan M.
      Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services prioritizing female exotic dancers.
      ). 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.

       Limitations

      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 (
      • Cipres D.
      • Seidman D.
      • Cloniger C.
      • Nova C.
      • O’Shea A.
      • Obedin-Maliver J.
      Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco.
      ).

       Conclusion

      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.

      References

        • American College of Obstetricians and Gynecologists
        ACOG committee opinion no. 554: Reproductive and sexual coercion.
        Obstetrics & Gynecology. 2013; 121: 411-415https://doi.org/10.1097/01.aog.0000426427.79586.3b
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        • Shannon K.
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      Biography

      Jessica L. Zemlak, MSN, RN, FNP-BC, PMHNP-BC, is a PhD candidate, Johns Hopkins School of Nursing, Baltimore, MD.
      Anna P. Bryant, MSN, RN, is a registered nurse, Emergency Department, Ochsner Health System, New Orleans, LA.
      Noelene K. Jeffers, PhD, CNM, IBCLC, is an instructor, School of Nursing & Health Studies, Georgetown University, Washington, DC.