Number 708 Reaffirmed December 2019
Committee on Health Care for Underserved Women
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women in collaboration with Jennefer A. Russo, MD, MPH.
ABSTRACT: The population of women who sell or exchange sex or intimate sexual services for material goods or services, also called “sex work,” often is unrecognized in the typical obstetric and gynecologic practice. The prevalence of this behavior among adult women is difficult to quantify because of its frequent omission from the routine sexual history by women and clinicians. Data on the prevalence of sex work in the United States are largely lacking. The American College of Obstetricians and Gynecologists supports increasing awareness about the health risks, preventive care needs, and limited health care services for female sex workers.
Obstetrician–gynecologists and other health care providers can help improve the recognition of sex workers and increase their access to preventive care through the following actions:
Ask about the exchange of sex for money, goods, or services when taking a sexual history. Consider using a self-completed history form. Obstetrician–gynecologists and other health care providers may choose an algorithmic approach when a patient discloses having more than one sexual partner over the past month or another predetermined period. Obstetrician–gynecologists and other health care providers also may consider posing these questions to patients who acknowledged active substance abuse concerns.
Be aware that women who engage in sex work may be at higher risk of sexually transmitted infections (STIs), sexual or physical violence, incarceration, and reproductive coercion than the general population. Adolescents also may be at higher risk.
Women who engage in sex work should receive all appropriate cancer screenings and vaccinations recommended by the American College of Obstetricians and Gynecologists.
Be aware of the special needs of this population for preexposure and postexposure prophylaxis for human immunodeficiency virus (HIV). (See Committee Opinion No. 595, Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus.)
Counsel sex workers about the health risks of engaging in sex work and consider more frequent visits for this population. Contribute to efforts to increase access to preventive and therapeutic health care for women who engage in sex work.
Advocate for more research to determine the prevalence of sex work and the health care needs of this population.
Discuss these recommendations with your colleagues so they are informed about this vulnerable group of women.
Sex work is the exchange of sex or other intimate services for money, drugs, or other resources. Although sex work (or prostitution) is illegal in all but one state, it occurs in all areas of the United States and obstetricians and gynecologists often care for these patients. The number of women who engage in this behavior in the United States is unknown because of the reluctance to report an illegal activity and concern about perceived health care provider bias. The limited literature on sex work demonstrates a clear relationship with a number of health risks. Although research suggests that sex work disproportionately occurs among women of lower socioeconomic status, women in all socioeconomic groups may engage in sex work. The stereotype of the sex worker soliciting sex on a street corner (“outdoor” sex work) may not be typical today, for example, because a sex worker may solicit sex through a website that may or may not be oriented specifically to this service (“indoor” sex work). She may be a student or be working other jobs at the same time and be virtually indistinguishable from other patients. Some sex work may be consensual whereas some may not 1. This Committee Opinion will not address sex trafficking. For more information, please see Committee Opinion No. 507, Human Trafficking.
Women may trade sex for money, drugs, or other resources and do so with varying context, frequency, and formality 2. For the purposes of this Committee Opinion, we will use the umbrella term “sex work” for this behavior. Other terms that often are used include “prostitution,” “transactional sex,” “survival sex,” or “exchange sex” 2. Sex work may include a variety of behaviors and practices, including street-based practices, massage parlor work, independent sexual massage, escort services, brothels, stripping or dancing, and pornography for specific customers 3. Pornography produced for widespread consumption will not be addressed in this Committee Opinion because the individual level health risks and preventive care needs may be different in the population of women who are involved in the production of mass market pornography.
Research on the prevalence of sex work and related health outcomes is limited and frequently focused on high-risk populations and behavior rather than a cross section of all women accessing the health care system. A few studies have looked at the prevalence of sex work in a family planning clinic population 2, a cross sectional survey of young women in Northern California 4, the National HIV Behavioral Surveillance survey 5, and the National Longitudinal Study of Adolescent Health 6. In these studies, the proportion of women who respond that they engaged in sex work currently or in the past ranged from 2% to 13%.
The underground sex economy is estimated to earn $290 million per year per city in some American urban areas 7. Much of this economy in the United States has shifted to solicitation through the internet, with women engaging in indoor sex work approximately 5–10 times more often than outdoor sex work 1.
Health Risks for Sex Workers
High-Risk Sexual Behavior
Lack of condom use during vaginal, anal, and oral sex; multiple sexual partners; sex while under the influence of drugs or alcohol; or unwanted sex are all more common in women who engage in sex work than in the general population 2 6 8 9 10. In a study of women who acknowledged sex work and who accessed services at a family planning clinic, 40% reported that they were offered more money for unprotected sex, 30% reported a history of client condom refusal, and 16.5% reported they were forced to have sex in the past 2.
Of note, a study based on self-reporting of 41 female sex workers in three of Nevada’s legal brothels showed excellent adherence to condom use (which is mandatory in the system) and low rates of breakage and slippage of condoms 11.
Sexually Transmitted Infections
Sexually transmitted infections are reported more frequently in women who engage in sex work. In one study, female sex workers were twice as likely as women who did not engage in sex work to have a previous case of chlamydial infection or gonorrhea, and they were four times as likely to report a history of syphilis 4. In a population of women engaging in sex work, 12.4% had gonorrhea, 6.8% had chlamydial infection, 1.8% had syphilis, and 34.3% had herpes simplex virus 2 at the time of screening 3. In another study of a population of women engaging in sex work and intravenous drug use, 5.7% tested positive for HIV, 13.1% for chlamydial infection, 1.9% for gonorrhea, 36.6% for trichomoniasis, and 28.1% for syphilis 10. Of women incarcerated in New York City jails who had engaged in sex work, 9% were found to be HIV positive 8. For each of these infections, the prevalence among women engaging in sex work is significantly higher than that of the U.S. population in general (0.479% for chlamydial infection, 0.124% for gonorrhea, 0.008% for syphilis, and 0.467% for HIV) 12 13. Sex workers engaged in collective sex work—those who collaborate with other sex workers—were significantly less likely to test positive for an STI (odds ratio [OR] 0.4; 95% CI, 0.1–0.9) 3.
Drug use is more common among sex workers than in the general population and may be a risk factor for engaging in sex work. In addition, drug use in sex work is associated with a high risk of violence against the sex worker 14. In one study, 41% of female sex workers reported smoking tobacco and 35.7% reported illicit drug use 3. The most common drug used by female sex workers was heroin 3. Use of marijuana and cocaine is associated with self-reported sex work in adolescents 6 9.
Female sex workers also may be at risk of violence. A systematic review of the literature on global sex work found that 45–75% of women reported a history of violence in their lifetime and 32–55% reported it during the previous year 14. Criminalization of sex work, economic pressure to participate in sex work, and social stigmatization of sex work were associated with an increased prevalence of violence 14.
Of female sex workers in San Francisco, 55% reported a history of family or partner violence and 36% reported a history of sex work-related violence 3. In this study, street-based sex work, massage parlor work, and stripping were associated with a higher incidence of workplace violence 3.
In a study of mortality in a cohort of sex workers in Colorado, homicide and accidents accounted for 19% and 12% of deaths, respectively 15. In this study, the workplace homicide rate for sex workers was 204 per 100,000, which is 50 times higher than the next highest workplace homicide rate (ie, for female liquor store workers) 15.
In addition to lower use of condoms because of incentives for higher pay, women who engage in sex work may have a higher risk of unintended pregnancy (adjusted risk ratio, 1.27; 95% CI, 1.09–1.48) and higher rate of abortion (adjusted risk ratio, 1.63; 95% CI, 1.19–2.23) 2 compared with young women who do not engage in sex work. A study of female sex workers in Vancouver, Canada, found that only 14% acknowledged condom use, 9% used depot medroxyprogesterone acetate, 1% used the birth control pill, 1% used intrauterine devices, and 16% used tubal ligation for contraception 16.
In a 2013 study of female sex workers at the U.S.–Mexico border, only 38% acknowledged current condom use and 38% reported current noncondom contraceptive use 10. The study also demonstrated a potential association of higher numbers of clients, sexual violence, and pregnancies ending in miscarriage in this population 10.
Among male, female, and transgender sex workers in San Francisco who attended a health clinic for sex workers, 70% reported that they had never disclosed their sex work behavior to their health care providers 3. Participants reported nondisclosure because of negative experiences in the past with health care workers, fear of disapproval, embarrassment, or because they determined that sex work was not relevant to their health care needs 3.
Based on the prevalence of sex work noted in the aforementioned studies, and the possible increasing prevalence related to the ability to solicit services online 1, health care providers should include direct questions about exchanging sex for money, goods, or drugs in a nonjudgmental manner during their sexual history-taking. Self-completed history forms may be more likely to provide more accurate responses, depending on the patient population. Furthermore, health care centers specifically geared toward serving a population of sex workers may be beneficial for ensuring a space where these women feel comfortable accessing reproductive health care 3.
Although the prevalence of sex work in the United States is difficult to quantify, obstetrician–gynecologists and other health care providers should be aware that it is likely more common than they suspect and they should screen for sex work during sexual history-taking. Awareness of sex work behavior can facilitate preventive health measures that may affect very high rates of infection, violence, and drug use in this population.