Introduction

Introduction
Mental health problems are a significant cause of the

global burden of disease. In 2010, mental, neurological,
and substance use disorders were the leading cause of
years lived with disability globally [1]. Worldwide, an
estimated 300 million people are affected by depression,
and 272 million people by anxiety, with women at
higher risk compared with men [2,3]. The treatment gap
for common conditions exceeds more than 90% in low-
income countries [4]. Left untreated, mental disorders
prevent people from reaching their full potential, impair
human capital, and are associated with premature
mortality from suicide and other illnesses [5]. Suicide is
a health outcome strongly associated with mental,
neurological, and substance use disorders. Nearly
800,000 people are estimated to die due to suicide each
year, with 79% of global suicides occurring in low- and
middle-income countries (LMICs) [6]. A range of social
determinants affect the risk and outcome of mental
disorders. These include demographic factors (such as
age, gender, and ethnicity), socioeconomic factors (such
as low income, unemployment, and low education),
neighbourhood factors (such as inadequate housing and
neighbourhood violence), and social change associated
with changes in income and urbanisation [1].
Sex work—defined by The Joint United Nations

Programme on HIV/AIDS (UNAIDS) as the receipt of
money or goods in exchange for sexual services, either
regularly or occasionally [7]—is criminalised in most
regions of the world [8]. In addition to the social
determinants described earlier, women who sell sex face
a unique set of structural factors including police
harassment and arrests, discrimination,
marginalization, poverty, and gender inequality [8,9], as
well as extreme occupational hazards such as violence,
coercion, deception, alcohol and substance use, and
human immunodeficiency virus (HIV)/sexually
transmitted infection (STI) [10]. Together, these
predispose female sex workers (FSWs) to increased
psychological health vulnerabilities. Structural and
occupational risks associated with sex work are highly
dependent on sociocultural and economic contexts,
which means that these hazards may differ for sex
workers in LMICs and those in high-income countries.
Evidence from high-income countries indicates a high
prevalence of mental health morbidity among FSWs,
especially post-traumatic stress disorder (PTSD),
depression, anxiety, and psychological distress [11–14].
Three previous reviews have examined mental health in
the context of STIs/HIV, alcohol use, and violence
against sex workers [15–17]. However, no attempt has
been made to date to synthesise the evidence or estimate
the burden of mental health disorders for FSWs. This is
vital to inform policy and programming at the global and
country level. The aim of this systematic review is to
estimate the prevalence of mental disorders among
FSWs in LMICs, and to examine associations with factors
that commonly affect their health and well-being
(violence, alcohol and drug use, condom use, HIV/STI).
Go to:
Methods
Search strategy and selection criteria
The review protocol has been registered with

PROSPERO, number CRD42016049179
(https://www.crd.york.ac.uk/prospero/). Ethics
approval was not required for this study. This study
follows the Preferred Reporting Items for Systematic
reviews and Meta-Analysis (PRISMA) guidelines (Fig
1; S1 Prisma Checklist). We searched electronic peer-
reviewed literature databases (Ovid, PubMed, Web of
Science) from first record until 26 April 2020. Search
terms included the following: “mental health” OR
“mental well-being” OR “psycholog* health” OR
“psycholog* distress” OR “mental illness*” OR “mental
disorder*” OR “mental health problem*” OR “psychiatr*
morbidit*” OR “anxiety” OR “depress*” OR “suicid*” OR
“trauma” OR “post-traumatic stress disorder” OR
“PTSD”; “sex work*” OR “female sex work*” OR
“prostitut*” OR “female prostitut*” OR “sex trad*” OR
“transact* sex” OR “FSW*” OR “commercial sex” OR
“sex-trade worker*”; “low and middle income countr*”
OR “LAMIC*” OR “LMIC*” OR “developing countr*” OR
“names of all countries which fit the LMIC criteria.”
See S1 Text for full database list and search strategy.
Articles were included that measured the prevalence or

incidence of mental health problems among FSWs, even
if sex workers were not the main focus of the study.
Only studies from countries defined as low or middle
income, in accordance with the World Bank income
groups 2019 [18], were included. Eligible studies had to
be peer-reviewed, include females aged 16 or older who
were actively engaged in sex work, and include the
following study designs: cross-sectional survey, case–
control study, cohort study, case series analysis, or
experimental study with baseline measures for mental
health. Studies were limited to English. We excluded
studies that used qualitative methods only, were review
papers, were conference abstracts, or were non–peer-
reviewed publications. Studies exclusively focused on
alcohol and substance use or victims of human
trafficking sold into sex work were excluded from this
review as reviews have recently been published in these
areas [17,19–21]. Studies focused on women engaged in
transactional sex only were ineligible for review, as this
practice—and its implications on health—is distinct from
sex work [22].
Data extraction and quality assessment
All publications were screened by 2 independent

reviewers (TB and BS). If either author classed a
publication as relevant, the abstract was reviewed, with
any disagreements discussed and a consensus reached. If
eligibility could not be determined by screening of the
title and abstract, the authors reviewed the full text.
Three authors (BS, TB, and AM) assessed full texts using
the eligibility criteria cited earlier, with any
discrepancies resolved through discussion. Data were
extracted by 3 authors (TB, BS, and AM) into a
structured data extraction sheet.
Study quality was assessed by authors (TB, BS, and AM)
using the Centre for Evidence-Based Management
(CEBM) Critical Appraisal for Cross-Sectional Surveys
Tool (S2 Text). One item on CEBM was removed (Item
12: “Can the results be applied to your organisation?”)
as it was not applicable to this review. To assess quality
of studies, authors rated each article on 11 items, and an
overall score was calculated, with higher scores
indicating stronger quality. Studies scoring ≥7 out of 11
points were considered strong quality, between 5 and 7
were rated moderate quality, and ≤4 were scored as
weak quality. Individual scores are presented in Table 1,
and detailed scoring of each study is presented in S3
Text.
Table 1
Studies and mental health outcomes.

Aut Coun Sample Sam Outc Met Event Sa Preva Re
hor try/in demograp pling ome( hod s m lence sea
and come hics proc s) of of pl (%) rch
year classif edur inter asses e qu
icatio e est sing siz alit
n outc e y
ome(
s)
AFRICA
Abe Came FSWs Resp Depre PHQ 1,067 2, Any Str

lson roon, Sex work onde ssion -9 16 level ong
(201 lower- location: nt with 5 depres (7)
9) middl Brothel, drive cut- sion:
e lodge, bar, n off > 49.8%
incom other samp 5
e entertainm ling
ent
establishm
n outc e y
ome(
s)
ent: 100%
Median
age: 30.1 y
(range: 23–
36)
Education:
Primary/le
ss: 30.9%
Secondary/
higher:
69.0%
Martial
status:
Never
married:
77.3%
Currently
married/in
relationshi
p: 10.7%
Divorced/s
eparated/
widowed:
12.0%
Aki Nigeri FSWs Purp Affec Awa 36 12 28.8% Mo

nna a, Sex work osive tion/ ritefe 5 der
wo lower- location: mood Psyc ate
(199 middl Brothel, disor holo (5)
5) e lodge, bar, der gical
incom other Inde
e entertainm x
ent
establishm Neur Eyse 25 20.0%
ent: 100% oticis nck
Age: 30.5 m Pers
n outc e y
ome(
s)
y (range: onali
not ty
reported) Inve
Education: ntory
not
reported
Married
status:
Never
married:
41.6%
Currently
married/in
relationshi
p: 44.0%
Divorced/s
eparated/
widowed:
14.4%
Bar Tanza Female bar Rand Depre PHQ 3 23 13.0% Mo

nhar nia, workers om ssion -9 der
t low Demograp samp meas ate
(201 incom hics not ling uring (6)
9) e reported mod
for FSWs erate
to
sever
e
usin
g
cut-
off >
10
n outc e y
ome(
s)
PTSD Prim 3 13.0%

ary
care
PTS
D
scree
ning
tool
usin
g
cut-
off
>3
Ber Swazi FSWs Resp Ever “Hav 188 32 58.6% Mo

ger land, Sex work onde suicid e 5 der
(201 lower- location: nt e you ate
8) middl Brothel, drive ideati ever (5)
e lodge, bar, n on felt
incom other samp like
e entertainm ling you
ent want
establishm ed to
ent: 27.0% end
Street/publ your
ic place: life?
8.7% ”
Home:
57.8%
Mean age:
26 y
(range: 16–
49)
Education:
Primary/le
ss: 32.4%,
n outc e y
ome(
s)
Secondary/
higher:
67.9%
Martial
status:
Never
married:
89.1%,
Currently
married/in
relationshi
p: 4.1%
Divorced/s
eparated/w
idowed:
6.9%
Bitt Togo, FSWs Resp Psych Kess Mild: 95 Mild: Mo

y- low Sex work onde ologi ler 223 2 23.4% der
And incom location: nt cal Psyc Sever Sever ate
erso e Brothel, drive distre holo e/mod e/mod (6)
n lodge, bar, n ss gical erate: erate:
(201 other samp Distr 181 19%
9)**, entertainm ling ess
Tch ent Scal
ank establishm e
oni ent: 100% (K10
(202 Median )
0)** age: 25 y, with
IQR 21–32 cut-
y off
Education: score
Primary/le s:
ss: 44.9% Mild
Secondary/ : 20–
higher: 24
n outc e y
ome(
s)
55.1% Mod
Marital erate
status: : 25–
Never 29
married: Seve
86.1% re:
currently >30
married/in
relationshi
p: 13.9%
Divorced/s
eparated/w
idowed:
0%
Can Burki FSWs Resp Ever “Eve 290 69 41.8% Mo

ge na Sex work onde depre r felt 5 der
(201 Faso, location: nt ssion sad ate
9) low not drive or (5)
incom reported n depr
e Mean age: samp esse
26 y ling d for
(range: 18– more
59) than
Education: 2
Primary/le week
ss: 53.8% s at a
Secondary/ time
higher: ”
0.7%
Martial Ever Ever 149 21.4%
status: suicid want
Never e ing
married: ideati to
53.6% on end
Currently their
n outc e y
ome(
s)
married/in life
relationshi at
p: 10.9% least
Divorced/s once
eparated/w
idowed:
35.5%
Coet South FSWs Resp Depre CES 349 50 68.7% Str

zee Africa Sex work onde ssion -D 8 ong
(201 , location: nt 20 (7)
8) upper- not drive usin
middl reported n g
e Median samp cut-
incom age: 31 y ling off
e (IQR: 25– >21
37)
Education: PTSD PTS 201 39.6%
Primary/le D-8
ss: 75.6% usin
Secondary/ g
higher: cut-
12.4% off
Relationshi >9
p status:
not Suici “In 15 2.9%
reported de the
ideati past
on in mont
past h has
mont the
h and thou
year ght
of
endi
ng
n outc e y
ome(
s)
your
life
been
in
your
mind
?”
“Wit
hin
the
past
year
have
you
felt
suici
dal
beca
use
you
are a
sex
work
er?”
Suici “In 5 1%
de past
attem year
pt in have
past you
year atte
mpte
d
suici
de?”
n outc e y
ome(
s)
Gro Togo FSWs and Resp Ever “Hav 284 1, 20.5% Mo

sso and MSM onde suicid e 38 der
(201 Burki Sex work nt e you 3 ate
9) na location: drive ideati ever (5)
Faso, not n on had
low reported samp suici
incom Median ling dal
e age: not thou
reported ghts?
Education: ”
primary/hi
gher:
57.0%
Martial
status: not
reported
Kim Burki FSWs and Resp Ever “Hav 80 35 22.9% Mo

(201 na MSM onde suicid e 0 der
8) Faso, Sex work nt e you ate
low location: drive ideati ever (5)
incom not n on felt
e reported samp like
Age ling you
(categories want
): ed to
<20: end
10.2% your
21–29: life?
37.8% ”
>30: 52%
Education:
not
reported
Martial
status:
n outc e y
ome(
s)
Never
married:
44.5%
Currently
married/in
relationshi
p: 4.3%
Divorced/s
eparated/w
idowed:
34.0%
Lion South FSWs who Resp Depre PHQ NA 53 NA Mo

(201 Africa use onde ssion -9 der
7) , methamph nt usin ate
upper- etamines drive g (6)
middl Sex work n cut-
e location: samp off
incom not ling >10
e reported
Age: 29 y PTSD PTS 21 38.7%
(range not D
reported) Bresl
Education: au’s
primary or 7
lower not item
reported s
Martial usin
status: not g
reported cut-
off
>4
Mala FSWs Purp Depre PHQ 16 20 8% Str

Mac wi, Sex work osive ssion -9 0 ong
Lea low location: usin (7)
n outc e y
ome(
s)
n incom Not g
(201 e reported cut-
8) Median off
age: 24 y >10
(IQR: 22–
28) PTSD PCL 16 8%
Education: usin
Primary/le g
ss: 17.0% cut-
Secondary/ off
higher: >38
2.0% and
Martial >44
status:
Never Suici Used 6 3%
married: de PHQ
14.0% ideati -9
Currently on item:
married/in past 2 “Hav
relationshi week e
p: 4.0 s you
Divorced/s had
eparated/w thou
idowed: ghts
81.0% you
woul
d be
bette
r off
dead
”
(pass
ive
ideat
ion)
and
n outc e y
ome(
s)
“of
hurti
ng
your
self
in
some
way”
(acti
ve
ideat
ion)
Ortb Ugan FSWs Rand Depre PHQ Ugand 96 43.2% Str

lad da, Sex work om ssion -9 a: 416 0 ong
(202 low location: samp usin (10
0) incom Not ling g )
e reported cut-
Median off >
age: 28 y 10
(IQR: 24–
32) Suici Used 302 31.5%
Education: de PHQ
Primary/le ideati -9
ss: 55.7% on item:
Secondary/ past 2 “Hav
higher: week e
43.1% s you
Marital had
status: Not thou
reported ghts
you
woul
d be
bette
r off
n outc e y
ome(
s)
dead
or of
hurti
ng
your
self
in
some
way”
Zambi Depre Zam 965 45

a, ssion bia: .7
lower- 441 %
middl
e Suici 540 56
incom de .7
e ideati %
on
past 2
week
s
Peit The FSWs Purp Depre Sad 154 24 62.6% Mo

zmi Gamb Sex work osive ssion or 6 der
er ia, location: depr ate
(201 low Not esse (6)
4)* incom reported d
Sher e Mean age: moo
woo 31 y d for
d (Range: 2 or
(201 17–51) more
5)* Education: week
Primary/le s at a
ss: 60.4% time
Secondary/ in
higher: the
n outc e y
ome(
s)
39.6% past
Martial 3
status: ever years
married:
23.0%
Currently
married/in
relationshi
p: 2.0%
Divorced/s
eparated/w
idowed:
69.8%
Poli South FSWs Purp Depre PHQ 121 15 80.9% Mo

ah Africa Sex work osive ssion -9 0 der
(201 , location: usin ate
7) upper- Not g (5)
middl reported cut-
e Mean age: off
incom not score
e reported >5
Education:
Primary/le Depre SRQ 120 78.4%
ss: 65.2% ssion -20
Secondary/ and usin
higher: anxiet g
34.8% y cut-
Martial off
status: score
Never >7
married:
94.8%
Currently
married/in
relationshi
n outc e y
ome(
s)
p: 2.6%
Divorced/s
eparated/w
idowed:
1.9%
Rhe Zimba FSWs Rand Psych Shon 43 17 24.7% Mo

ad bwe, Sex work om ologi a 4 der
(201 lower- location: samp cal Sym ate
8) middl Not ling distre ptom (6)
e reported of ss Ques
incom Age range: venu tionn
e 19–58 y es aire
Education: follo Cut-
Primary/le wed off
ss: 42.5% by not
Secondary/ respo repor
higher: ndent ted
57.5% drive
Marital n
status: samp
Never ling
married:
4.6%
Currently
married/in
relationshi
p: 50.0%
Divorced/s
eparated
/widowed:
44.8%
Rob Kenya HIV- Purp Depre PHQ 30 28 10.6% Mo

erts , negative osive ssion -9 3 der
lower- FSWs usin
n outc e y
ome(
s)
(201 middl Sex work g ate

8) e location: cut- (6)
incom Brothel, off
e lodge, bar, score
other >10
entertainm
ent PTSD PCL 63 22.1%
establishm -C
ent: 88.0% usin
Street/publ g
ic place: cut-
0% off
Home: score
12.1% >30
Median
age: 33.5 y
(IQR:
27.2–40.6)
Education:
3.1 y (IQR:
1.2–9.8)
Marital
status: not
reported
EASTERN MEDITERRANEAN
Lari Iran, FSWs with Nonp Psych Sym NA 12 NA We

(201 upper- history of robab ologi ptom 5 ak
4) middl drug use ility cal Chec (4)
e who are samp distre klist-
incom engaged le ss 90
e with harm Cut-
reduction off
centres not
Sex work
n outc e y
ome(
s)
location: repor
not ted
reported
Mean age:
32.5 y
(range: 16–
51)
Education
status: only
reported
for
secondary:
39.2%
Marital
status: only
reported
for
divorced:
>50.0%
Ranj Iran, FSWs Purp Ment GH 30 48 62.5% We

bar upper- Sex work osive al Q-28 ak
(201 middl location: health usin (4)
9) e not disor g
incom reported ders cut-
e Age: 30.9 off
y (range: score
18–45) >23
Education
and Struc 16 53.5%
relationshi tured
p status: Clini
not cal
reported Inter
view
for
n outc e y
ome(
s)
DS
M-
IV
moo
d
disor
ders
Struc 11 36.7%
tured
Clini
cal
Inter
view
for
DS
M-
IV
anxi
ety
disor
ders
EUROPE
Lan Arme FSWs Purp Depre CES 53 11 45% Mo

g nia, Sex work osive ssive -D-8 7 der
(201 lower- location: sympt item ate
1) middl Street/publ oms usin (5)
e ic place: g
incom 100% cut-
e Median off
age: 33.8 y >7
(range: 20–
52)
Education
n outc e y
ome(
s)
and
relationshi
p status:
not
reported
SOUTH EAST ASIA
Gho India, HIV- Purp Depre Hosp 30 10 30% Mo

se lower- positive osive ssion ital 0 der
(201 middl FSWs Anxi ate
5) e attending Anxie ety 44 44% (5)
incom an HIV ty Depr
e clinic essio
Sex work n
location: Sche
Brothel, me
lodge, bar, Cut-
other off
entertainm not
ent repor
establishm ted
ent: 92%
Street/publ
ic Place:
8%
Mean age:
23 y
Education
and
relationshi
p status:
not
reported
n outc e y
ome(
s)
Hen Bangl FSWs Resp Major WH 11 25 4.2% Mo

gart adesh, Sex work onse depre O 9 der
ner lower- location: drive ssive Ment ate
(201 middl Brothel, n disor al (6)
5) e lodge, bar, samp der Heal
incom other ling th
e entertainm Gener Com 54 20.8%
ent alised posit
establishm anxiet e
ent: 71.8% y Inter
Home: disor natio
61.8% der nal
Mean age: Diag
23.2 y PTSD nosti 8 3.1%
(range 11– c
48) Inter
Education: view
Yes: Cut-
23.0%; off
No: 77.0% not
Marital repor
status: ted
Currently
married/in
relationshi
p: 23.2%
Iais India, FSWs Purp Major MIN 9 10 9% We

ukla lower- enrolled in osive depre I 0 ak
ng middl an HIV ssive Inter (4)
(201 e programm disor natio
7) incom e der nal
e Sex work Psyc
location: Gener hiatri 8 8%
not alised c
reported anxiet Inter
n outc e y
ome(
s)
Mean age: y view

29.5 y disor cut-
Educationa der off
l status: not
Primary/le PTSD repor 21 21%
ss: 24.0% ted
Secondary/
higher:
45.0%
Martial
status:
Never
married:
9.0%
Currently
married/in
relationshi
p: 34.0%
Divorced/s
eparated/w
idowed:
57.0%
Pan India, FSWs who Purp Depre GH 142 20 71% We

diya lower- use alcohol osive ssion Q 0 ak
n middl or drugs, item (3)
(201 e attending Anxie s not 84 42%
2) incom psychiatric ty speci
e outpatient fied
department Cut-
Demograp off
hics not not
reported repor
ted
Clini
cal
n outc e y
ome(
s)
inter
view
to
confi
rm
diag
nosis
Pate India, FSWs Rand Depre PHQ 696 2, 29% Str

l lower- Sex work om ssion -2 40 ong
(201 middl location: samp usin 0 (9)
6) e Brothel, ling g
incom lodge, bar, cut-
e other off
entertainm >3
ent
establishm
ent: 27.6%,
street/publi
c place:
4.5%,
Home:
13.9%,
Mobile
phones:
54%
Mean age:
31.0 y
Education:
Yes:
43.8%, No:
56.2%
Marital
status:
Never
married:
n outc e y
ome(
s)
5.0%
Currently
married/in
relationshi
p: 66.5%
Divorced/s
eparated/w
idowed:
28.5%
Pate India, FSWs Rand Depre PHQ 778 1, 39.2% Str

l lower- Sex work om ssion -2 98 ong
(201 middl location: samp usin 6 (9)
5) e Brothel, ling g
e other off
entertainm >3
ent
establishm
ent: 7.7%
Street/publ
ic place:
63.8%,
Home:
28.5%
Age,
education,
and
relationshi
p status:
not
reported
Sha India, FSWs Resp Depre Kess NA 32 NA Str

hma lower- Sex work onde ssion ler- 6 ong
nesh middl location: nt and 10 (7)
n outc e y
ome(
s)
(200 e Brothel, drive anxiet Cut-

9) incom lodge, bar, n y off
e other samp not
entertainm ling repor
ent ted
establishm
ent: 57.6% Suici Suici 114 34.9%
Street/publ de de
ic place: ideati item
22.8% on s not
Home: past 3 descr
28.1% mont ibed
Mean age: hs
not
reported Suici 61 18.7%
Education: de
Yes: attem
32.7%, No: pts
67.3% past 3
Martial mont
status: hs
Never
married:
28.4%
Currently
married/in
relationshi
p: 31.3%
Divorced/s
eparated/w
idowed:
40.3%
Sure India, FSWs Purp Depre CES 49 57 86% We

sh lower- Sex work osive ssion -D ak
middl location: cut- (4)
n outc e y
ome(
s)
(200 e Street/publ off

9) incom ic place: not
e 100% repor
Mean age: ted
34 y
(range: 20– PTSD PCL 31 56%
27) -C
Educationa usin
l: g
Secondary: cut-
51% off
Marital >45
status: not
reported Ever Ever 17 30%
suicid havi
e ng
ideati thou
on ghts
of
suici
de at
the
level
of
form
ing a
plan
WESTERN PACIFIC
Bro Camb Female Two- Psych GH 284 65 43.2% Str

dy odia, entertainm stage ologi Q- 7 ong
(201 low ent cluste cal 12: (8)
6) incom workers r distre mea
e Sex work samp ss n
location: ling score
n outc e y
ome(
s)
Brothel, meth for

lodge, bar, od whol
other e
entertainm samp
ent le
establishm used
ent: as
100.0% cut-
Mean age: off
25.6 y
Education: Suici Suici 128 19.5%
Formal de de
education: ideati item
6.4 y on s not
(mean) past 3 descr
Marital mont ibed
status: hs
Never
married: Suici 48 7.3%
44.1% de
Currently attem
married/in pts
relationshi past 3
p: 28.6% mont
Divorced/s hs
eparated/w
idowed:
27.2%
Carl Mong FSWs with Purp Depre BSI 134 22 60.4% Mo

son olia, harmful osive ssion depr 2 der
(201 lower- level of essio ate
7) middl alcohol use n (5)
e Demograp subs
incom hics not cales
e reported usin
n outc e y
ome(
s)
g
cut-
off
>63
Che China, FSWs Rand Depre CES 189 45 41.3% Mo

n upper- working in om ssion -D 7 der
(201 middl commercia samp 20 ate
7) e l sex ling usin (5)
incom venues venu g
e Sex work es cut-
location: and off
Brothel, purpo score
lodge, bar, sive >16
other select
entertainm ion
ent of
establishm FSW
ent: 100% s
Mean age:
25.2 y
(range: 18–
42)
Education:
Secondary/
less: 7.4%
Secondary/
higher:
25.5%
Marital
status:
Never
married:
30.2%
Currently
married/in
n outc e y
ome(
s)
relationshi
p: 63.2%
Divorced/s
eparated/w
idowed:
6.0%
Gu China, FSWs who Snow Depre Depr NA 23 NA Mo

(201 upper- inject ball ssion essio 4 der
0a) middl drugs samp n ate
e Sex work ling subs (6)
incom location: cale
e Brothel, of
lodge, bar, Chin
other ese
entertainm Depr
ent essio
establishm n
ent: 100% Anxi
Mean age: ety
not Stres
reported s
Education: Scal
Secondary/ e
below: Cut-
75.5% off
Secondary/ not
higher: repor
24.5% ted
Marital
status not Hopel Chin NA NA
reported essne ese
ss Hop
eless
ness
Scal
n outc e y
ome(
s)
e
Cut-
off
not
repor
ted
Gu China, FSWs who Conv Psych "You 155 21 71.8% Mo

(201 upper- inject enien ologi hate 6 der
0b) middl drugs ce cal your ate
e Sex work Distre self (5)
incom location: ss very
e not muc
reported h"
Mean age:
28.1 y "You 167 77.3%
Education: feel
Primary/le very
ss: 17.6% depr
Secondary/ esse
higher: d"
82.4%
Marital "You 142 65.7%
status: are
Never suffe
married: ring
53.7% from
Currently sever
married/in e
relationshi inso
p: 19.0% mnia
Divorced/s "
eparated/w
idowed:
26.4%
n outc e y
ome(
s)
Gu China, FSWs who Snow Depre Depr 78 20 39.0% Mo

(201 upper- inject ball ssion essio 0 der
4) middl drugs samp n ate
e Sex work ling subs (6)
incom location: cale
e Brothel, of
lodge, bar, Chin
other ese
entertainm Depr
ent essio
establishm n
ent: 100% Anxi
Mean age: ety
33.9 y Stres
Education: s
Primary/le Scal
ss: 13.6% e
Secondary/ usin
higher: g
86.4% cut-
Marital off
status: >21
Never
married: Suici "Hav 89 44.7%
36.0% de e
Currently ideati you
married/in on thou
relationshi past 6 ght
p: 46.5% mont of
Divorced/s hs com
eparated/w mitti
idowed: ng
17.5% suici
de in
the
past
n outc e y
ome(
s)
6
mont
hs?"
Suici “Hav 54 26.8%

de e
attem you
pt atte
past 6 mpte
mont d to
hs com
mit
suici
de in
the
past
6
mont
hs?”
Hon China, FSWs Purp Depre CES 94 31 30.3% Mo

g upper- Sex work osive ssion D-10 0 der
(201 middl location: usin ate
0) e Brothel, g (6)
e other off
entertainm score
ent of
establishm >16
ent: 100%
Median Suici “In 55 17.8%
age: 22.5 y de the
(range: 16– ideati past
42) on 6
Education: past 6 mont
<6 y: hs,
n outc e y
ome(
s)
33.6%, 7–9 mont have

y: 48.1% hs you
>9 y: thou
29.6% ght
Marital of
status: Not com
married: mitti
85.5%, ng
Currently suici
married/in de?”
relationshi
p: 14.5% Suici “In 28 9.0%
de the
attem past
pt 6
past 6 mont
mont hs,
hs have
you
atte
mpte
d to
com
mit
suici
de?”
Hon China, FSWs Rand Suici “In 40 45 14.2% Str

g upper- Sex work om de the 4 ong
(200 middl location: samp ideati past (7)
7a)* e Brothel, ling on 6
**
, incom lodge, bar, venu past 6 mont
Fan e other es mont hs,
g entertainm and hs have
(200 ent purpo you
7)*** establishm sive thou
n outc e y
ome(
s)
, ent: select ght

Wan 100.0% ion of
g Mean age: of com
(200 23.5 y FWS mitti
7)*** Education s ng
(y): 5.8 y suici
Marital de?”
status:
Never Suici “In 23 8.4%
married: de the
60.0% attem past
Currently pt 6
married/in past 6 mont
relationshi mont hs,
p: 35.2% hs have
Divorced/s you
eparated/w atte
idowed: mpte
4.9% d to
com
mit
suici
de?”
Hon China, FSWs Purp Depre CES 174 27 62.6% Mo

g upper- Sex work osive ssion -D 8 der
(200 middl location: 10 ate
7b) e Street/publ usin (6)
incom ic place: g
e 100% cut-
Mean age: off
23.5 y score
Education ≥16
(y): 5.84 y
(mean)
Martial
n outc e y
ome(
s)
status:
Never
married:
57.5%
Currently
married/in
relationshi
p: 35.2%
Divorced/s
eparated/w
idowed:
6.9%
Hon China, FSWs Rand Depre CES 502 1, 49.1% Str

g upper- Sex work om ssion -D 02 ong
(201 middl location: samp 10 2 (8)
3)†, e Brothel, ling usin
Su incom lodge, bar, venu g
(201 e other es cut-
4)†, entertainm and off
Zha ent purpo score
ng establishm sive ≥16
(201 ent: 91.2%, select
4a)†, Mini hotels ion Sever Ever 97 9.5%
Zha and streets: of e “seri
ng 8.7% FSW suicid ousl
(201 Mean Age: s e y
4b)†, 24.8 y ideati consi
Zha Education on or dere
ng status: suicid d
(201 Primary/le e killin
7)† ss: 63.4% attem g
Secondary/ pt your
higher: self”
36.6% or
Marital ever
n outc e y
ome(
s)
status: “trie
Never in d to
relationshi kill
p: 71.5% your
Ever in self”
relationshi
p: 28.5% Ever Ever 83 8.0%
suicid “seri
e ousl
ideati y
on consi
dere
d
killin
g
your
self
Ever Ever 49 4.8%

suicid “trie
e d to
attem kill
pt your
self”
China, FSWs Rand Depre CES 34 15 22.1% Str

Hua upper- Sex work om ssion -D 4 ong
ng middl location: samp usin (7)
(201 e Brothel, ling g
4)§, incom lodge, bar, venu cut-
Zall e other es off
er entertainm and >20
(201 ent purpo
4)§, establishm sive Anxie Soci 6 3.9%
Yan ent: select ty al
g 100.0% ion anxi
n outc e y
ome(
s)
(201 Median of ety

8)§ age: 23.5 y FSW scale
(IQR 20.9– s usin
26.4 y) g
Education: cut-
Secondary/ off
less: >60
56.7%
Secondary/ Suici Suici 15 9.7%
higher: de de
43.5% ideati ideat
Marital on ion
status: past item
Currently year not
married/in descr
relationshi ibed
p: 44.5%,
Single/div Suici Suici 9 5.8%
orced/wido de de
wed: attem atte
54.4% pt mpt
past item
year not
descr
ibed
(auth
ors
note
d
havi
ng
plan
as
indic
ating
an
n outc e y
ome(
s)
atte
mpt)
Suici Suici 8 5.2%

dal de
behav beha
iour vior
past not
year descr
ibed
Jack China, FSWs Purp Depre CES NA 39 NA We

son upper- Sex work osive ssion -D 5 ak
(201 middl location: cut- (4)
3) e Brothel, off
incom lodge, bar, not
e other repor
entertainm ted
ent
establishm
ent and
street/publi
c place:
100%
Mean age:
26.7 y
Education:
Primary/le
ss: 13.9%
Secondary/
higher:
86.9%
Marital
status:
Currently
married/in
n outc e y
ome(
s)
relationshi
p: 64.4%
Mut Camb HIV Purp Psych Kess 27 88 31% Mo

h odia, positive osive ologi ler- der
(201 lower- FSWs cal 10 ate
7) middl Sex work distre cut- (6)
e location: ss off
incom Brothel, not
e lodge, bar, repor
other ted
entertainm
ent
establishm
ent:
100.0%
Median
age: 32 y
(IQR: 28–
35)
Education:
Primary/le
ss: 85.0%
Secondary/
higher:
15.0%
Martial
status: not
reported
Offr Mong FSWs Rand Depre BSI NA 20 NA Str

inga olia, Sex work om ssion depr 4 ong
(201 lower- location: samp essio (7)
7) middl Brothel, ling n
e lodge, bar, subs
other cale
n outc e y
ome(
s)
incom entertainm Cut-

e ent off
establishm not
ent and repor
street/publi ted
c place:
100%
Mean age:
35.2 y
Education:
Primary/le
ss: 7.8%
Secondary/
higher:
92.2%
Martial
status:
Divorced/s
eparated/w
idowed:
52.3%
Sagt Nepal, FSWs Snow Depre CES 173 21 82.4% Str

ani low Demograp ball ssion -D 0 ong
(201 incom hics not samp 20 (8)
3) e reported ling usin
g
cut-
off
>16
She China, FSWs Conv Depre GH 342 65 52.4% Mo

n upper- working in enien ssion Q-12 3 der
(201 middl commercia ce Chin ate
6) e l sex samp ese (6)
venues ling versi
n outc e y
ome(
s)
incom Sex work on

e location: usin
Brothel, g
lodge, bar, samp
other le
entertainm mea
ent n
establishm score
ent and as
street/publi cut-
c place: off
100%
Mean age:
not
reported
Education:
Primary/le
ss: 23.4%
Secondary/
higher:
76.5%
Marital
status: Not
married:
42.3%
Currently
married:
43.6%
Shre Nepal, FSWs (and Rand Depre CES 112 61 18.3% Str
stha low MSM/trans om ssion -D 0 ong
(201 incom ) samp usin (7)
7) e Sex work ling g
location: cut-
Brothel, off
lodge, bar, >22
n outc e y
ome(
s)
other Ever Suici 210 4.4%

entertainm suicid de
ent e item
establishm ideati not
ent and on descr
street/publi ibed
c place:
100%
Mean age:
not
reported
Education
by literacy
status:
Yes:
67.8%
No: 32.1%
Marital
status:
Currently
married/in
relationshi
p: 59.0%
Ura Philip FSWs Purp Depre CES 83 14 58% Mo

da pines, Sex work osive ssion -D 3 der
(201 lower- location: 24 ate
3) middl Brothel, usin (6)
e lodge, bar, g
incom other cut-
e entertainm off
ent >23
establishm
ent:
100.0%
Median
n outc e y
ome(
s)
age: 22 y
(IQR: 20–
25)
Education:
10 y (IQR
9–10)
Martial
status:
Currently
married/in
relationshi
p: 29.0%
Living
alone/separ
ated/wido
wed: 71%
Witt Mong FSWs who Purp Depre BSI- 19 48 38% We

e olia, had recent osive ssion depr ak
(201 lower- unprotecte essio (4)
0) middl d sex with n
e client, subs
incom enrolled in cale
e National Cut-
AIDs off
Foundation score
Program not
Sex work repor
location: ted
not
reported
Mean age:
28 y (range
18–40)
Education:
Secondary/
n outc e y
ome(
s)
higher:
100%
Marital
status:
Never
married:
67.0%
Yan China, Female Rand Depre CES 20 40 50% Mo

g upper- migrants om ssion -D der
(200 middl engaged in samp 20 ate
5) e sex work ling usin (6)
incom Sex work of g
e location: venu cut-
Brothel, es off
lodge, bar, and >16
other conv
entertainm enien
ent ce
establishm samp
ents: le of
100.0% FSW
Mean age: s
23.9 y
(mean)
Education:
Secondary/
less:
92.3%
Marital
status:
Never
married:
76.9%
AMERICAS
n outc e y
ome(
s)
Dev Brazil FSWs Purp Depre Hosp 11 83 13.2% Mo

ógli , Sex work osive ssion ital der
o upper- location: Anxi ate
(201 middl not Anxie ety 33 39.7% (5)
7) e reported ty and
incom Mean age: Depr
e 26.8 y essio
Education: n
Secondary/ scale
less: Cut-
30.1% off
Higher not
than repor
secondary: ted
92.6%
Relationshi
p status:
Never
married:
94.0%
Currently
married/in
relationshi
p: 6.0%
Divorced/s
eparated/w
idowed:
4.8%
Gon Mexic FSWs Purp Depre MIN 41 10 39.8% We

zále o, Sex work osive ssion I 3 ak
z- upper- location: Inter (3)
Fort middl Brothel, natio
eza e lodge, bar, nal
(201 incom other Psyc
4) e entertainm hiatri
n outc e y
ome(
s)
ent c
establishm Inter
ent: 48% view
Street/publ ,
ic place: inclu
16% ding
Median suici
age: 28.8 y de
Education: risk
Primary/le
ss: 31.4% Ever MIN 40 38.8%
Secondary/ suicid I
higher: e risk Inter
60.8% natio
Marital nal
status: Psyc
Never hiatri
married: c
49.0% Inter
Currently view
married/in ,
relationshi inclu
p: 28.0% ding
Divorced/s suici
eparated/w de
idowed: risk:
22.3% “Do
you
ever
feel
like
life
is
not
wort
h
n outc e y
ome(
s)
livin
g?”
“Hav
e
you
ever
thou
ght
abou
t
killin
g
your
self.
If so,
how
woul
d
you
do
it?”
Jain Mexic FSWs Purp Depre Beck 106 29 35.9% Mo

(201 o, Sex work osive ssion Depr 5 der
9) upper- location: essio ate
middl not n (5)
e reported Inve
incom Median ntory
e age: 38 y usin
(IQR: 20– g
46) cut-
Education: off
Secondary: score
44.1% >20
Marital
n outc e y
ome(
s)
status: not
reported
Logi Jamai FSWs who Purp Depre PHQ 42 45 93.33 Mo

e ca, are lesbian osive ssion -2 % der
(201 upper- and usin ate
8) middl bisexual g (6)
e women cut-
incom Sex work off
e location: >3
not
reported
Mean age:
27.2 y
(range: 19–
43)
Education:
not
reported
Marital
status:
Never
married:
8.9%
Currently
married/in
relationshi
p: 71.1%
Rael Domi HIV- Purp Depre CES 245 34 70.20 Mo

(201 nican negative osive ssion -D 9 % der
7a)‡, Repub FSWs with samp 10 ate
Rael lic, dependent le usin (6)
(201 upper- children g
7b)‡ middl Sex work cut-
e location:
n outc e y
ome(
s)
incom Brothel, off

e lodge, bar, >10
other
entertainm
ent
establishm
ent: 70.1%
Mean age:
27.5 y
Education:
8.4 y
(mean)
Marital
status:
Currently
married/in
relationshi
p: 32.4%
Sem Mexic FSWs in Time Depre Beck 155 42 36.4% Mo

ple o, street- - ssion Depr 6 der
(201 upper- based work locati essio ate
9) middl and on n (6)
e establishm samp Inve
incom ent-based ling ntory
e indoor sex usin
work g
Sex work cut-
location: off
Brothel, score
lodge, bar, >20
other
entertainm
ent
establishm
ent: 39.0%
n outc e y
ome(
s)
Street/publ
ic place:
61.0%
Mean age:
33.6 y
(range: 18–
56)
Education:
Primary/le
ss: 41.8%,
secondary/
higher:
59.1%
Marital
status:
Never
married:
56.0%
Currently
married/in
relationshi
p: 28.8%
Divorced/s
eparated/w
idowed:
14.7%
Ulib Mexic HIV- Purp Psych Brief NA 91 NA Mo

arri o, negative osive ologi Sym 6 der
(200 upper- FSWs cal ptom ate
9)Ꝁ, middl Sex work distre Inve (5)
Ulib e location: ss ntory
arri incom Brothel, (depr Subs
(201 e lodge, bar, essio cales
4)Ꝁ other n and :
entertainm somat depr
n outc e y
ome(
s)
ent izatio essio

establishm n) n
ent: 41.2% and
Street/publ soma
ic place: tizati
54.8%, on
Other: (cut-
3.2% off
Mean age: not
33.4 y repor
(range 18– ted)
64)
Education:
6.13 y
(mean)
Marital
status:
Never
married:
46.0%
Currently
married/in
relationshi
p: 33.0%
Divorced/s
eparated/w
idowed:
26.0%
Ulib Mexic FSWs who Purp Depre CES 538 62 86.2% Mo

arri o, inject osive ssion -D 4 der
(201 upper- drugs 10 ate
3) middl Sex work usin (6)
e location: g
incom not cut-
e reported
n outc e y
ome(
s)
Mean age: off

33.7 y >10
Educationa
l status: 7.1
y (mean)
Martial
status:
Never
married:
49.0%
Currently
married/in
relationshi
p: 38.0%
Divorced/s
eparated/w
idowed:
13.3%
Ulib Mexic FSWs who Snow Depre CES NA 21 NA Mo

arri o, use drugs ball ssion -D 4 der
(201 upper- and have a samp 10 ate
5) middl regular ling cut- (5)
e partner off
incom Sex work not
e location: repor
not ted
reported
Mean age:
37.3 y
(mean)
Education:
6.7 y
(mean)
Marital
status:
n outc e y
ome(
s)
Currently
married/in
relationshi
p: 98.0%
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*Papers report findings on same study but explore

different associations with outcome of interest.
**Papers report findings on same study but explore

***Papers report findings on same study but explore

†
Papers report findings on same study but explore
§
‡
Ꝁ
Abbreviations: BSI, Brief Symptom Inventory; CES-D,
Centre for Epidemiological Studies Depression Scale;
DSM-IV, Diagnostic and Statistical Manual of Mental
Disorders, 4th edition; FSW, female sex worker; GHQ,
General Health Questionnaire; HIV, human
immunodeficiency virus; IQR, interquartile range; MINI,
Mini-International Neuropsychiatric Interview; MSM,
men who have sex with men; NA, not applicable; PCL,
PTSD CheckList; PCL-C, PTSD CheckList – Civilian
Version; PHQ, Patient Health Questionnaire; PTSD, post-
traumatic stress disorder; SRQ, WHO Self-Reporting
Questionnaire.
Data analysis
A narrative synthesis was conducted across all studies

meeting inclusion criteria. Prevalence estimates were
calculated from percentages or raw proportions, and we
contacted authors of studies in which raw data were
missing. If multiple publications reported results from a
single study, we included all studies in Table 1 but only
the original study in the narrative synthesis and
prevalence analyses. Meta-analyses were conducted on
studies that scored moderate to strong in the quality
assessment and that used validated measures to assess
mental health outcomes; we excluded studies from the
meta-analyses that sampled participants based on
characteristics that are known to be an independent risk
factor for mental health problems (such as injecting
drug use or HIV status) and could therefore bias the
pooled mental health estimates. Analyses were
completed using Comprehensive Meta-Analysis (CMA)
software version 3 (Biostat, Englewood, NJ). Pooled
estimates were calculated using a random effects model.
Variation between studies was determined by
heterogeneity tests with the Higgins’ I2 statistic. Relative
weights were calculated using the formula 1/V +
T2 where V is the error variance and T2 (Tau-squared) is
the between-study variance. Subgroup analyses were
completed to examine associations between mental
health outcomes (e.g., depression) and the following
covariates: violence/police arrest, alcohol/drug use,
condom use, and HIV/STI. Due to variations between
studies in the factors adjusted for in multivariate
analyses, unadjusted odds ratios (ORs) were extracted
or calculated from raw data. Pooled effect estimates
were calculated using a random-effects model.
Go to:
Results
Study characteristics
The initial electronic search yielded 1,035 results, with

11 more studies identified through reference list
screening and online searches. After duplicate records
were removed, the titles and abstracts of 630
publications were screened for eligibility. Of those, 208
were identified as potentially relevant publications and
reviewed for inclusion. Sixty-eight papers reporting on
56 unique studies with 24,940 participants meeting the
inclusion criteria (Fig 1). Eight of these studies did not
provide prevalence data on mental health [23–31];
authors of these studies were contacted twice for further
information, and 2 authors responded, providing
prevalence data [23,27]. In total, 86 prevalence
estimates from 48 studies were available
(depression n = 37; anxiety n = 7; PTSD n = 8; suicide
attempt n = 8; suicide ideation n = 17; psychological
distress n = 7; mood disorders n = 2) (Table 1).
Studies were based in 26 LMICs: 13 countries in sub-

Saharan Africa, 1 in the Middle East and north Africa
region, 1 in Eastern Europe, 2 in South East Asia, 5 in
the Western Pacific region, and 4 in Latin America and
the Caribbean. Eleven studies reported findings from
countries in the low-income group, 20 studies from the
low-middle income group, and 26 studies from the
upper-middle income group, as per the World Bank
income classification. Twenty-nine studies used a
purposive sample, 14 used respondent driven sampling
techniques, 7 used a random sample, and 6 utilized
random sampling techniques to select venues and
purposive methodology to recruit FSWs within these
venues (Table 1). Most studies recruited FSWs from a
variety of venues, such as streets, bars, brothels, and
entertainment establishments, with 3 studies selecting
women from clinics or hospital settings [26,32,33]. All
studies were cross-sectional, with 3 studies including
qualitative data alongside survey results [34–36]. Of the
56 studies, 14 scored as strong quality, 34 scored as
moderate, and 8 scored as weak (S3 Text). Sixteen
studies (14 moderate; 2 weak) selected participants
based on harmful alcohol or drug use (n = 9)
[24,26,31,33,34,37–40], or positive [32,41] or negative
[29,42–45] HIV status (n = 5), and were excluded from
the meta-analyses (regardless of CEBM score) to avoid
biasing the pooled estimates. Analyses used a variety of
validated scales and cut-off points to assess mental
disorders (Table 1). None reported a mental health
intervention.
The mean age of FSWs in the 42 studies that reported

this was 28.9 years (age range: 11–64 years). Thirty-two
studies reported sex work locations for their sample;
among these studies, 66.3% of FSWs worked in brothels,
lodges, bars, or other entertainment establishments;
51.7% worked in streets or public places; 24.7% worked
at home; and 36.7% worked in other settings, e.g., via
mobile phones (these categories were not mutually
exclusive). Thirty-one studies reported education levels
of their sample, and among these, nearly one-half of
FSWs (45.7%) had an education level of primary school
or less. Among the 40 studies that reported marital
status for their sample, 48% of FSWs were never
married; 32.9% were currently married or in a
relationship; and 24.5% were divorced, separated, or
widowed.
Mental disorders and suicidal behaviour
Forty-four studies examined depression among FSWs,

with 37 reporting prevalence estimates (Table 1)
[9,10,23,27,32–37,39,43–69]. A meta-analysis was
conducted with 23 studies (Fig 2). The pooled
prevalence of depression among FSWs from LMICs is
41.8% (95% CI 35.8%–48.0%). Seven studies reported
on the prevalence of anxiety among FSWs
[9,32,33,50,58,64,70], with 3 included in the meta-
analysis (Fig 3). The pooled prevalence of anxiety among
FSWs from LMICs is 21.0% (95% CI 4.8%–58.4%).
PTSD symptomology was reported in 8 studies
[9,10,23,40,43,46,47,50] with 4 studies included in the
meta-analysis (Fig 4). The pooled prevalence of PTSD
symptoms among FSWs from LMICs is 19.7% (95% CI
3.2%–64.6%). Ten studies measured psychological
distress among FSWs, with 7 studies providing
prevalence estimates [38,41,49,70–73] and 4 studies
included in the meta-analysis (Fig 5). The pooled
prevalence of psychological distress experienced by
FSWs from LMICs was 40.8% (95% CI 20.7%–64.4%).
Two studies examined mood disorders [70,74]. Only one
study [74] was eligible for inclusion in a meta analysis
and thus a pooled prevalence estimate is not available.
This study reported a prevalence of affection/mood
disorder of 28.8% (95% CI 21.5%–37.3%).
Seventeen studies reported on suicidal ideation

[10,36,39,46,47,55,57,58,61,69,71,75–80]. Most assessed
suicidal ideation by asking about suicidal thoughts, for
example, “have you thought about killing yourself?” and
“have you ever felt like you wanted to end your life?”
For the meta-analysis, we divided studies based on
timeframe into ‘recent’ or ‘ever’ suicidal ideation and
removed 3 studies due to limitations in how questions
were operationalized [46,47], including one study that
combined suicidal thoughts with attempting suicide
[65]. The pooled prevalence of recent (past 3 months, 6
months, or year) suicide ideation is 22.8% (95% CI
13.2%–36.5%) (n = 6 studies from 7 countries) (Fig 6).
The pooled prevalence of lifetime suicidal ideation is
24.9% (95% CI 15.0%–38.3%) (n = 6 studies) (Fig 7).
Eight studies reported on suicide attempts among FSWs
[39,46,55,57,58,71,79,80]. The majority assessed suicide
attempts through one binary question (yes/no) asking
whether the participant had attempted suicide.
Prevalence of recent suicide attempt (past 3 months, 6
months, or year) was reported by 6 studies included in
the meta-analysis (Fig 8). The pooled prevalence of
recent suicide attempts among FSWs from LMICs is
6.3% (95% CI 3.4–11.4%). Only one study reporting on
ever suicide attempt was eligible for inclusion in a meta
analyses and thus a pooled prevalence estimate is not
available. This study reported a prevalence of lifetime
suicide attempt of 4.8% (95% CI 3.6%–6.3%) [81].
Associations between mental health and other factors
We conducted subgroup analyses to examine

associations between mental health (e.g., depression)
and factors commonly experienced by FSWs
(violence/police arrest, alcohol/drug use, condom use,
and HIV/STI) (Table 2). Findings of the meta-analyses
are summarised in Table 3 and displayed in forest plots
in S1–S4 Figs.
Table 2
Studies on mental health and outcomes of interest.

Autho Coun Sam Menta Outcome Sa Odd Odds Cr Pv
r and try ple l (s) of mpl s in in the ud alu
study health interest e the unex e e
measu size expo posed O
re sed1 2 R
(95
%
CI)
VIOLENCE
Berger Swaz FSW Suicide Physical 325 124/ 67/68 1.9 0.0
(2018) iland s ideatio violence 65 (1. 06
n ever (as a 2–
result of 3.0
selling )
sex) or
sexual
violence
ever
Cange Burki FSW Suicide Physical 696 106/ 318/2 1.7 0.0
(2019) na s ideatio violence 43 20 (1. 08
Faso n ever ever 2–
2.5
)
Sexual 91/5 193/3 2.9 <0.

violence 8 53 (2. 001
ever 0–
4.2
)
Carlso Mong FSW Depres Physical 222 114/ 67/21 1.8 0.0
n olia s with sion violence 20 (0. 9
(2017) harmf (BSI) ever by 9–
ul client 3.5
level )
of
alcoh Sexual 79/5 24/64 3.8 <0.
ol use violence 5 (2. 001
ever by 1–
client 6.9
)
re sed1 2 R
(95
%
CI)
Coetz South FSW Depres Physical 508 295/ 142/2 1.4 0.2
ee Afric s sion or sexual 41 8 (0.
(2018) a (CES- violence 8–
D) past year 2.4
)
PTSD 244/ 195/3 1.5 0.1

(PTSD 31 8 (0. 3
-8) 9–
2.6
)
Gu China FSW Depres Verbal, 200 25/5 25/97 1.8 0.0

(2014) s who sion physical 3 3 6
inject (Chine violence (1.
drugs se or threats 0–
Depres past 6 3.5
sion months )
Anxiet by clients
y or
Stress gatekeepe
Scale) rs
Suicide 33/5 16/94 3.4 0.0

ideatio 6 (1. 01
n past 6–
6 7.0
months )
Suicide 22/3 26/11 3.2 0.0

attempt 0 6 (1. 1
past 6 3–
months 7.6
)
re sed1 2 R
(95
%
CI)
Hong China FSW Depres Sexual 278 17/1 3/101 1.5 0.6
(2007 s sion violence 57 (0.
b) (CES- past 6 4–
D) months 5.9
)
Suicide 18/4 52/33 2.5 0.0

ideatio 7 7 (1. 04
n past 3–
6 4.6
months )
Suicide 14/2 60/35 3.5 0.0

attempt 4 6 (1. 01
past 6 7–
months 7.1
)
Hong China FSW Depres Sexual, 1,0 252/ 244/2 1.6 <0.
(2013) s sion physical, 22 170 71 (1. 001
* (CES- or 3–
Zhang D) emotional 2.1
(2017) violence )
* ever by
client
Sexual, 241/ 124/1 1.9 <0.

physical, 189 89 (1. 001
or 4–
emotional 2.6
violence )
ever by
intimate
partner
re sed1 2 R
(95
%
CI)
Suicide Sexual, 55/3 37/47 1.9 0.0

ideatio physical, 67 8 (1. 06
n or or 2–
attempt emotional 3.0
ever violence )
ever by
client
Sexual, 52/3 15/29 2.7 0.0

physical, 78 8 (1. 01
or 5–
emotional 5.0
violence )
ever by
intimate
partner
Depres Sexual, 358/ 279/2 1.7 <0.

sion physical, 163 22 (1. 001
(CES- or 4–
D) emotional 2.3
violence )
ever by
intimate
partner or
non-
partner
Suicide Sexual, 79/1 558/3 2.9 <0.

ideatio physical, 8 67 (1. 001
n or or 7–
attempt emotional 4.9
ever violence )
ever by
intimate
partner or
re sed1 2 R
(95
%
CI)
non-
partner
Jain Mexi FSW Depres Physical 295 50/5 57/13 2.1 0.0
(2020) co s sion violence 6 2 (1. 02
(PHQ- ever by 3–
9) client 3.4
)
Patel India FSW Depres Physical 1,9 158/ 189/1 1.4 0.0
(2015) s sion violence 86 620 020 (1. 08
(PHQ- past 6 1–
2) months 1.7
)
Police 165/ 133/1 2.2 <0.

arrest 613 075 (1. 001
ever 7–
2.8
)
Patel India FSW Depres Physical 2,4 285/ 291/1 3.3 <0.
(2016) s sion or sexual 00 418 407 (2. 001
(PHQ- violence 7–
2) past year 4.0
)
Poliah South FSW Depres Violence 150 93/2 17/11 2.2 0.0
(2017) Afric s sion ever 7 (0. 8
a (PHQ- during 9–
9) sex work 5.3
)
re sed1 2 R
(95
%
CI)
Police 85/3 19/8 0.9 0.9

harassme 8 (0.
nt ever 4–
2.3
)
Robert Keny HIV- Depres Sexual, 283 26/4 197/5 1.8 0.3
s a negat sion physical, 6 (0.
(2018) ive (PHQ- moderate 6–
FSW 9) emotional 5.5
s violence )
ever by
PTSD intimate 41/5 182/5 2.5 0.0
(PCL- partner or 5 (0. 7
C) non- 9–
partner 6.6
)
Sagtan Nepal FSW Depres Physical, 210 90/6 10/48 7.0 <0.
i s sion sexual, or 2 (3. 001
(2013) (CES- emotional 2–
D) violence 15.
past 6 1)
months
Shah India FSW Suicide Sexual 326 18/5 18/23 4.3 <0.
manes s attempt violence 5 4 (2. 001
h past 3 ever 1–
(2009) months 8.7
)
Sexual, 38/5 29/44 2.3 0.0

physical, 5 (1. 1
or verbal 2–
violence 4.3
past 12 )
re sed1 2 R
(95
%
CI)
months
by
intimate
partner
Sexual, 29/4 40/21 3.5 0.0

physical, 4 2 (2. 01
or verbal 0–
violence 6.2
past 12 )
months
by others
Police 18/5 32/22 2.3 0.0

raid past 5 0 (1. 1
12 2–
months 4.3
)
Sherw Gam FSW Sad or Sexual 251 51/1 19/71 1.9 0.0
ood bia s depress violence 00 (1. 5
(2015) ed ever by 0–
mood client 3.5
for )
more
than 2
weeks
at a
time in
past 3
years
Ulibar Mexi FSW Depres Physical 624 269/ 35/49 1.4 0.1
ri co s who sion violence 269 (0.
(2013) ever 9–
re sed1 2 R
(95
%
CI)
inject (CES- 2.2

drugs D) )
Physical 108/ 15/69 1.2 0.6

violence 430 (0.
ever by 6–
client 2.1
)
Sexual 283/ 30/54 2.0 0.0

violence 255 (1. 06
ever 2–
3.2
)
Ulibar Mexi HIV- Psycho Physical, 924 NA NA 2.0 <0.

ri co negat logical sexual, or (1. 001
(2014) ive distress emotional 6–
FSW (BSI) violence 2.4
s past 6 )
months
by clients
ALCOHOL AND DRUG USE
Bitty- Togo FSW Psycho Harmful/ 952 82/9 350/4 1.0 1.0
Ander s logical hazardous 9 21 (0.
son distress alcohol 7–
(2019) (Kessle (AUDIT) 1.4
*
, r) )
Tchan
koni
(2020)
*
re sed1 2 R
(95
%
CI)
Coetz South FSW Depres Severe 508 196/ 81/55 0.8 0.2
ee Afric s sion binge 174 (0.
(2018) a (CES- drinking 5–
D) (AUDIT) 1.1
)
PTSD 99/9 179/1 0.8 0.2

(PTSD 6 34 (0.
-8) 5–
1.1
)
Hong China FSW Depres Alcohol 454 62/1 26/78 1.7 0.0
(2007 s sion intoxicati 12 (1. 5
a) (CES- on past 6 0–
D) months 2.9
)
Suicide 31/34 118/ 1.7 0.0

ideatio 221 (1.0– 6
n past 2.9)
6
months
Suicide 21/17 128/ 2.8 0.0

attempt 288 (1.4– 03
past 6 5.4)
months
Jain Mexi HIV- Depres Hazardou 295 57/4 79/11 1.6 0.0
(2020) co negat sion s alcohol 9 0 (1. 5
ive (PHQ- past year 0–
FSW 9) (AUDIT) 2.6
s )
re sed1 2 R
(95
%
CI)
Polydrug 45/6 40/14 2.8 <0.

use past 1 9 (1. 001
month 6–
4.6
)
Patel India FSW Depres Alcohol 1,9 493/ 455/7 2.9 <0.
(2015) s sion use past 86 285 51 (2. 001
(PHQ- 30 days 4–
2) 3.4
)
Zhang China FSW Depres Illicit 1,0 118/ 67/43 1.9 <0.
(2014 s sion drug use 22 403 4 (1. 001
a) (CES- ever 4–
D) 2.6
)
Zaller China FSW Depres Alcohol 358 19/3 76/23 1.8 0.0
(2014) s sion dependent 2 1 (1. 6
***
, (CES- (AUDIT 0–
Yang D) ≥16) 3.4
(2018) )
***
Suicide Alcohol 11/8 22/24 1.4 0.4

ideatio dependent 4 1 (0.
n past (AUDIT 7–
12 ≥16) 3.1
months )
Depres Illicit 15/9 12/23 3.1 0.0

sion drug use 6 5 (1. 05
(CES- ever 4–
D) 6.8
)
re sed1 2 R
(95
%
CI)
CONDOM USE
Abels Came FSW Depres Inconsiste 2,1 108/ 391/1 1.4 0.0
on roon s sion nt 36 274 363 (1. 13
(2019) (PHQ- condom 1–
9) use with 1.8
clients )
ever
Brody Camb FSW Psycho Inconsiste 657 235/ 322/5 0.8 0.2
(2016) odia s logical nt 49 1 (0.
distress condom 5–
(GHQ- use with 1.2
12) clients )
past 3
months
Inconsiste 255 340/ 0.9 0.6

nt /29 33 (0.5–
condom 1.4)
use with
partner
past 3
months
Gu China FSW Depres Inconsiste 234 NA NA 1.2 <0.

(2010 s who sion nt (1. 001
a) inject (Chine condom 1–
drugs se use with 1.3
Depres clients )
sion past 6
Anxiet months
y
Stress
Scale)
re sed1 2 R
(95
%
CI)
Hong China FSW Depres Inconsiste 278 140/ 62/42 2.8 <0.
(2007 s sion nt 34 (1. 001
b) (CES- condom 6–
D) use with 4.8
clients )
Patel India FSW Depres Inconsiste 1,9 274/ 277/9 1.8 <0.
(2015) s sion nt 86 504 28 (1. 001
(PHQ- condom 5–
2) use 2.2
occasiona )
l clients
Inconsiste 356/ 342/8 2.1 <0.

nt 41 45 (1. 001
condom 8–
use with 2.6
regular )
clients
Shah India FSW Suicide Inconsiste 326 26/4 63/18 4.3 <0.
manes s attempt nt 7 9 (2. 001
h past 3 condom 1–
(2009) months use with 8.7
clients )
Shen China FSW Depres No 653 69/2 64/24 1.0 1.0

(2016) s sion condom 70 5 (0.
(GHQ) last sex 7–
client 1.4
)
No 70/1 120/1 0.4 <0.

condom 38 05 (0. 001
last sex 3–
partner
re sed1 2 R
(95
%
CI)
0.7
)
Urada Philip FSW Depres Inconsiste 143 47/6 13/23 1.4 0.4
(2013) pines s sion nt 0 (0.
(CES- condom 6–
D) use with 3.0
clients )
Zaller China FSW Depres Inconsiste 358 16/9 16/23 1.6 0.0
(2014) s sion nt 5 1 (1. 18
***
, (CES- condom 2–
Yang D) use with 2.1
(2018) clients )
***
past 6
months
Inconsiste 67/4 138/1 1.2 0.4

nt 4 09 (0.
condom 9–
use with 1.9
partner )
past 6
months
HIV/STIs
Bitty- Togo FSW Psycho HIV 952 80/1 45/72 12. <0.
Ander s logical positive 01 6 8 001
son distress (8.
(2019) (Kessle 4–
*
, r) 19.
Tchan 5)
koni
(2020)
*
re sed1 2 R
(95
%
CI)
Cange Burki FSW Suicide HIV 696 22/1 56/39 1.5 0.1
(2019) no s ideatio positive 04 5 (0. 4
Faso n ever 9–
2.6
)
Jain Mexi HIV- Depres Syphilis, 295 32/7 24/16 3.0 <0.
(2020) co negat sion chlamydi 4 5 (1. 001
ive (PHQ- a, or 6–
FSW 9) gonorrhoe 5.4
s a positive )
MacL Mala FSW Depres HIV 200 12/3 126/5 1.9 0.3
ean wi s sion positive 9 (0.
(2018) (PHQ- 5–
9) 6.9
)
PTS 10/6 128/56 0.7 1.6

D (0.3
(PCL –
-C) 2.1)
Ortbla Ugan FSW Depres HIV 711 57/1 136/3 1.1 0.6
d da s sion positive 43 75 (0.
(2020) (PHQ- 8–
9) 1.6
)
Suicide 45/9 148/4 1.4 0.1

ideatio 3 25 (0. 1
n 9–
2.1
)
re sed1 2 R
(95
%
CI)
Zamb Depr HIV 682 65/ 158/ 1.8 0.0

ia essio positiv 86 373 (1.2– 02
n e 2.6)
(PHQ
-9)
Suici 85/ 138/ 1.4 0.0

de 142 317 (1.0– 6
ideati 1.9)
on
Peitz Gam FSW Sad or HIV 246 31/1 9/87 2.4 0.0
meier bia s depress positive 23 (1. 3
(2014) ed 1–
mood 5.4
for )
more
than 2
weeks
at a
time in
past 3
years
Poliah South FSW Depres HIV 150 93/1 22/6 1.5 0.5
(2017) Afric s sion positive 7 (0.
a (PHQ- 5–
9) 4.2
)
Shen China FSW Depres HIV 653 3/33 1/310 2.7 0.4
(2016) s sion positive 9 (0.
(GHQ) 3–
26.
5)
re sed1 2 R
(95
%
CI)
Syphilis 13/3 20/29 0.6 0.1

positive 29 1 (0.
3–
1.2
)
Hepatitis 8/33 5/306 1.5 0.5

C positive 4 (0.
5–
4.5
)
Mostrar menos
1
Odds in the exposed (e.g., Depression and
Violence/Depression and No Violence).
2
Odds in the unexposed (e.g., No Depression and
Violence/No Depression and No Violence).
*Studies use same data source.
***Studies use same data source but different cut-off for

depression.
Abbreviations: AUDIT, Alcohol Use Disorders

Identification Test; BSI, Brief Symptom Inventory; CES-
D, Centre for Epidemiological Studies Depression Scale;
FSW, female sex worker; GHQ, General Health
Questionnaire; HIV, human immunodeficiency virus; OR,
odds ratio; PCL-C, PTSD CheckList Civilian Version;
PHQ, Patient Health Questionnaire; PTSD, post-
traumatic stress disorder; STI, sexually transmitted
infection.
Table 3
Mental health problems and associations with

common risk factors.
Risk factor Total Number of Pooled OR P value
number of studies included (95% CI)
studies in meta-analysis
Violence
Depression and 13 7 2.2 (1.4– <0.001

violence (recent or 3.3)
ever)
Depression and recent 6 5 2.3 (1.3– 0.005

violence 4.2)
Recent suicide attempt 3 2 3.5 (2.3– <0.001

and violence (recent or 5.5)
ever)
Alcohol and drug use
Depression and alcohol 5 4 [3 with outlier 1.6 (0.8– 0.2,

use removed] 3.1), 2.1 <0.001
(1.4–3.2)
Recent suicide ideation 2 2 1.6 (1.0– 0.003

and alcohol use 2.5)
Depression and illicit 3 2 2.1 (1.4– <0.001

drug use 3.1)
Condom use
Risk factor Total Number of Pooled OR P value
number of studies included (95% CI)
studies in meta-analysis
Depression and 7 6 1.6 (1.2– 0.001

inconsistent condom 2.1)
use with clients
Depression and 2 2 0.7 (0.3– 0.5

inconsistent condom 1.9)
use with a regular
partner
HIV and STIs
Depression and HIV 4 4 (5 countries) 1.4 (1.1– 0.005

1.8)
Suicidal ideation (ever 2 2 (3 countries) 1.4 (1.1– 0.04

or recent) and HIV 1.8)
Mostrar menos
Abbreviations: HIV, human immunodeficiency virus;

STI, sexually transmitted infection
Violence
Seventeen studies reported on associations between

mental health problems and violence experience
[30,34,36,37,39,43,44,46,49,52,53,57,59,75,79,80,82],
usually by an intimate partner or a client (Table 2).
Measures of violence varied by timeframe (recent versus
ever), typology (physical, sexual, emotional) and
perpetrator (client, intimate partner, etc.). Overall, 13
studies reported associations between depression and
violence [34,37,39,43,44,46,49,52,53,59,79,83], with 7
studies included in the meta-analyses (S1 Fig). The
pooled unadjusted OR of depression and violence
experience (ever or recent) is 2.2 (1.4–3.3), p < 0.001
(n = 7 studies), and the pooled unadjusted OR of
depression and recent violence experience is 2.3 (1.3–
4.2), p = 0.005 (n = 5 studies). Two studies [43,46]
reported associations between PTSD and violence
experience (ever or recent), with only one of these
eligible for inclusion in a meta-analysis (unadjusted OR
is 1.5 [0.8–2.6], p = 0.13) [46]. One study [30] with HIV-
negative FSWs reported associations between
psychological distress and recent violence by clients
(unadjusted OR 2.0 [1.6–2.4], p < 0.001). One study
reported suicide ideation ever and physical (unadjusted
OR 1.7 [1.2–2.5], p = 0.008) or sexual violence
experience ever (unadjusted OR 2.9 [2.0–4.2], p <
0.001) [36], and 2 studies reported recent suicidal
ideation and violence experience (ever or recent), with
only one of these eligible for inclusion in a meta-analysis
(unadjusted OR 2.5 [1.3–4.7], p = 0.004) [79]. Three
studies reported recent suicide attempt and violence
experience (ever or recent), with 2 of these eligible for
inclusion in a meta-analysis (S1 Fig). The pooled
unadjusted OR of recent suicide attempt and violence
experience (ever or recent) is 3.5 [2.2–5.5], p < 0.001.
Three studies reported on police violence (harassment,

arrest, or raids) and mental health problems (Table 2).
While no association was found between police
harassment (ever) and current depression (unadjusted
OR 0.9 [0.4–2.3], p = 0.9) [49], police arrest (ever) was
associated with current depression in one study by Patel
and colleagues (unadjusted OR 2.2 [1.7–2.8], p < 0.001)
[53], and police raid in the past year was associated
with a suicide attempt in the past 3 months (unadjusted
OR 2.3 [1.2–4.3], p = 0.01) in a study by Shahmanesh
and colleagues [80].
Alcohol and drug use
Associations between mental health problems and

alcohol use were reported by 6 studies, but there was
marked variation in how alcohol use was measured,
with 2 studies asking about alcohol use in the past 30
days [53] or alcohol intoxication in the past 6 months
[56] and 4 studies using Alcohol Use Disorders
Identification Test (AUDIT) to measure hazardous,
harmful, or dependent drinking [44,73,84] or severe
binge drinking [46] (Table 2). The pooled unadjusted OR
for depression and alcohol use is 1.6 (0.8–3.1), p = 0.2 (n
= 4 studies) (S2 Fig); when the outlier study is removed
from the analyses, the pooled unadjusted OR is 2.1 (1.4–
3.2), p < 0.001 (n = 3 studies) (S2 Fig). Psychological
distress and harmful drinking was reported by one study
(unadjusted OR 1.0 [0.7–1.4], p = 1.0) [73]. The pooled
unadjusted OR of recent suicide ideation and alcohol use
is 1.6 (1.0–2.5), p = 0.03 (n = 2 studies) (S2 Fig); one
study reported associations between a recent suicide
attempt and alcohol use, with an unadjusted OR of 2.8
(1.4–5.5), p = 0.003.
Three studies reported on mental health problems and

illicit drug use, again with considerable variation in the
way illicit drug use was measured (any illicit drug use
ever [85,86] versus polydrug use past month [44]). Two
studies were included in the meta-analysis (S3 Fig). The
pooled unadjusted OR for depression and illicit drug use
is 2.1 (1.4–3.1), p < 0.001.
Condom use
Nine studies reported on mental health problems and

condom use with clients and regular partners
[24,53,56,60,62,68,71,80,84]. Condom use measurement
varied with studies either reporting frequency of
condom use (always versus not always) or condom use
at last sex (yes/no). The pooled unadjusted OR for
depression and inconsistent condom use with clients is
1.6 (1.2–2.1), p = 0.001 (n = 6 studies) (S3 Fig). The
pooled unadjusted OR for depression and inconsistent
condom use with a regular partner is 0.7 (0.3–1.9), p
= 0.5 (n = 2 studies) (S3 Fig). One study reported on
recent suicide attempt and inconsistent condom use with
clients; the unadjusted OR was 4.3 (2.1–8.7), p < 0.001.
HIV/STIs
Eight studies reported on HIV/STI and mental health

problems [36,44,47–49,60,69,73]. One study [48] was
excluded from the meta-analyses because it did not use a
validated tool to measure depression, and one study was
excluded because it only sampled HIV-negative women
[44]. The pooled unadjusted OR for depression and HIV
is 1.4 (1.1–1.8), p = 0.005 (n = 4 studies from 5
countries) and for suicidal ideation and HIV is 1.4 (1.1–
1.8), p = 0.04 (n = 2 studies from 3 countries) (S4 Fig).
One study reported associations between depression and
current syphilis infection; the unadjusted OR was 0.6
(0.3–1.2), p = 0.1 [60].
Go to:
Discussion
In this systematic review and meta-analysis using data
from 56 studies and 24,940 participants, we found that
mental health problems are highly prevalent among
FSWs in LMICs and are strongly associated with social
and behavioural factors commonly experienced by FSWs.
Of note, all studies were cross-sectional, and not a single
intervention study designed to address mental disorders
among FSWs was identified. The prevalence of mental
disorders among FSWs in LMICs was much higher
compared with the general population in LMICs. For
example, data from 41 LMICs from the 2002–2004
World Health Survey found the prevalence of depression
to range between 3.9% and 7.8%, with higher rates
among women (7.0%–7.8%) compared with men
(3.9%–4.9%) [87]. Additionally, the 12-month
prevalence of suicidal behaviour among people in LMICs
has been reported to be 2% for suicidal ideation and
0.4% for suicide attempts, with rates higher among
women compared with men (ideation: 2.4% women
versus 1.6% men; attempt: 0.5% women versus 0.4%
men) [88]. FSWs face increased levels of key risk factors
for mental disorders and suicidal behaviour, including
financial stress, low education, inadequate housing,
violence, alcohol and drug use, STIs including HIV, and
stigma and discrimination [15, 17, 53, 67], which may
help explain the higher prevalence of mental health
problems in comparison with the general population.
Indeed, findings from our meta-analyses support this
hypothesis. Understanding how these social
determinants interact with mental disorders and which
are modifiable within programmatic timeframes will be
crucial to designing holistic interventions for FSWs.
This review adhered to PRISMA guidelines and used a

comprehensive search strategy, independent screening
and quality appraisal of studies. This study had some
limitations. By limiting the search to published studies
only, and to literature written in English, we may have
missed key studies. We used unadjusted ORs to examine
associations between mental health problems and key
risk factors to allow like-for-like comparisons between
studies; not adjusting for potential confounders may
have biased the findings although unadjusted and
adjusted ORs were usually similar in individual studies.
Where individual studies provided multiple estimates on
co-linear outcomes (e.g., depression and violence;
depression and police arrest), using unadjusted ORs to
calculate the individual associations may have led to
participants who had not experienced one outcome (e.g.,
police arrest) but who had experienced the other (e.g.,
violence) being included in the reference group and
subsequent underestimation of the true association. The
removal of studies that sampled participants based on
characteristics that are known to be an independent risk
factor for mental health problems (such as HIV status,
harmful alcohol use) led to fewer studies being included
and wider confidence intervals around prevalence
estimates and pooled ORs. However, when we re-ran the
analyses to include all qualifying studies, regardless of
sampling criteria, we did indeed find that estimates
were slightly higher, suggesting that inclusion of these
studies would have led to an overestimation of the
pooled estimates and associations. Several
methodological issues across the studies were also
observed. All studies were cross-sectional. Longitudinal
studies are needed to ascertain direction of causality
between mental health problems and other factors
common to FSWs, although studies with the general
population suggest that these relationships are likely to
be bidirectional [89]. Most studies used nonprobability
sampling across a wide variety of settings which may
introduce selection bias and mean that the most
vulnerable women will be missed from these surveys.
This in turn may lead to underestimations of mental
health estimates. A range of measurement tools was
used to capture mental health outcomes, as well as
violence, alcohol and drug use, and condom use. Even
when studies used the same mental health outcome
measures, different cut-off scores were applied. This
limits the comparability and reliability of findings across
studies and points to a need for establishing more
rigorous guidelines on using validated tools with this
study population.
To our knowledge, this systematic review is the first

globally to estimate the prevalence of mental health
problems among FSWs in LMICs and to examine
associations between poor mental health and other risk
factors common in sex workers’ lives. Our findings and
meta-analyses suggest that FSWs experience a high
burden of depression, anxiety, PTSD, psychological
distress, and suicidal behaviours and that poor mental
health is strongly associated with violence experience,
drug use, inconsistent condom use, and HIV/STI.
Together, this supports the concept of overlapping
vulnerabilities and has several important implications.
First, there are no existing studies that we are aware of

that describe mental health interventions; low-cost,
effective interventions for FSWs with mental health
disorders are urgently needed. Among the general
population attending primary care services in India and
elsewhere, brief psychological interventions delivered
by trained lay-counsellors have been shown to
effectively treat depression [90,91]. Strategies to
prevent suicide could include promoting mental health,
limiting access to the means for suicide, reducing
harmful alcohol use and violence experience, and
training “gatekeepers” to support women at increased
risk, such as those who have previously attempted
suicide [6]. Such interventions should also be suitable
for FSWs and could be adapted and embedded within
existing HIV service provision. Second, the strong
associations between mental health disorders and key
occupational risk factors such as violence and harmful
alcohol and drug use support the need for upstream
structural interventions as part of holistic HIV
prevention programming for FSWs. Again, violence
interventions have been shown to be effective in
reducing violence among women in LMICs [92,93] as
well as among FSWs [94]. Low-cost, brief psychological
interventions to treat harmful alcohol use could also be
adapted to FSW settings [95]. Third, strong associations
between poor mental health and reduced condom use
with clients and with HIV infection suggest that
treatment of mental health problems may also improve
condom use with clients and the sexual and reproductive
health of FSWs. In addition, women diagnosed with HIV
may require on-going counselling and support, for
example, by HIV testing and screening counsellors or
FSW peer advocates, which goes beyond CD4 counts and
treatment adherence, to also enquire about a woman’s
ongoing psychological well-being.
Go to:
Supporting information
S1 PRISMA Checklist
PRISMA, Preferred Reporting Items for Systematic

reviews and Meta-Analyses.
(DOC)
Click here for additional data file.(53K, doc)

S1 Text
Database search strategies.
(DOCX)
Click here for additional data file.(20K, docx)
S2 Text
CEBM critical appraisal tool.
CEBM, Centre for Evidence-Based Management.
(DOCX)

S3 Text
Quality assessment of quantiative studies.
(DOCX)

S1 Fig
Meta-analyses summarising the associations between

mental health problems and violence.
(TIF)
Click here for additional data file.(936K, tif)

S2 Fig

mental health problems and alcohol use.
(TIF)

S3 Fig

mental health problems and illicit drug use and
condom use with clients and intimate partners.
(TIF)

S4 Fig

mental health problems and HIV infection.
HIV, human immunodeficiency virus.
(TIF)

Go to:
Abbreviations
AUDIT Alcohol Use Disorders Identification Test
CEBM Centre for Evidence-Based Management
FSW female sex worker
HIV human immunodeficiency virus
IQR interquartile range
LMIC low- and middle-income country
OR odds ratio
PRISMA Preferred Reporting Items for Systematic reviews and Meta-Analysis
PTSD post-traumatic stress disorder
STI sexually transmitted infection
UNAIDS The Joint United Nations Programme on HIV/AIDS
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Introduction

Mental health problems are a significant cause of the

Sex work—defined by The Joint United Nations

The review protocol has been registered with

Articles were included that measured the prevalence or

All publications were screened by 2 independent

Studies and mental health outcomes.

Abe Came FSWs Resp Depre PHQ 1,067 2, Any Str

Aki Nigeri FSWs Purp Affec Awa 36 12 28.8% Mo

Bar Tanza Female bar Rand Depre PHQ 3 23 13.0% Mo

PTSD Prim 3 13.0%

Ber Swazi FSWs Resp Ever “Hav 188 32 58.6% Mo

Bitt Togo, FSWs Resp Psych Kess Mild: 95 Mild: Mo

Can Burki FSWs Resp Ever “Eve 290 69 41.8% Mo

Coet South FSWs Resp Depre CES 349 50 68.7% Str

Gro Togo FSWs and Resp Ever “Hav 284 1, 20.5% Mo

Kim Burki FSWs and Resp Ever “Hav 80 35 22.9% Mo

Lion South FSWs who Resp Depre PHQ NA 53 NA Mo

Mala FSWs Purp Depre PHQ 16 20 8% Str

Ortb Ugan FSWs Rand Depre PHQ Ugand 96 43.2% Str

Zambi Depre Zam 965 45

Peit The FSWs Purp Depre Sad 154 24 62.6% Mo

Poli South FSWs Purp Depre PHQ 121 15 80.9% Mo

Rhe Zimba FSWs Rand Psych Shon 43 17 24.7% Mo

Rob Kenya HIV- Purp Depre PHQ 30 28 10.6% Mo

(201 middl Sex work g ate

Lari Iran, FSWs with Nonp Psych Sym NA 12 NA We

Ranj Iran, FSWs Purp Ment GH 30 48 62.5% We

Lan Arme FSWs Purp Depre CES 53 11 45% Mo

SOUTH EAST ASIA

Gho India, HIV- Purp Depre Hosp 30 10 30% Mo

Hen Bangl FSWs Resp Major WH 11 25 4.2% Mo

Iais India, FSWs Purp Major MIN 9 10 9% We

Mean age: y view

Pan India, FSWs who Purp Depre GH 142 20 71% We

Pate India, FSWs Rand Depre PHQ 696 2, 29% Str

Pate India, FSWs Rand Depre PHQ 778 1, 39.2% Str

Sha India, FSWs Resp Depre Kess NA 32 NA Str

(200 e Brothel, drive anxiet Cut-

Sure India, FSWs Purp Depre CES 49 57 86% We

(200 e Street/publ off

Bro Camb Female Two- Psych GH 284 65 43.2% Str

Brothel, meth for

Carl Mong FSWs with Purp Depre BSI 134 22 60.4% Mo

Che China, FSWs Rand Depre CES 189 45 41.3% Mo

Gu China, FSWs who Snow Depre Depr NA 23 NA Mo

Gu China, FSWs who Conv Psych "You 155 21 71.8% Mo

Gu China, FSWs who Snow Depre Depr 78 20 39.0% Mo

Suici “Hav 54 26.8%

Hon China, FSWs Purp Depre CES 94 31 30.3% Mo

33.6%, 7–9 mont have

Hon China, FSWs Rand Suici “In 40 45 14.2% Str

, ent: select ght

Hon China, FSWs Purp Depre CES 174 27 62.6% Mo

Hon China, FSWs Rand Depre CES 502 1, 49.1% Str

Ever Ever 49 4.8%

China, FSWs Rand Depre CES 34 15 22.1% Str

(201 Median of ety

Suici Suici 8 5.2%

Jack China, FSWs Purp Depre CES NA 39 NA We

Mut Camb HIV Purp Psych Kess 27 88 31% Mo

Offr Mong FSWs Rand Depre BSI NA 20 NA Str

incom entertainm Cut-

Sagt Nepal, FSWs Snow Depre CES 173 21 82.4% Str