What Do Sex Workers Need For Their Health?

For two years, Deutsche Aidshilfe conducted a participatory qualitative study on the needs of sex workers. On this page, we summarize the results and present the recommendations. You will also find contact details below.

Background:

Sex workers are not a homogeneous group. Their life situations are very diverse, they have
different gender identities and the contexts in which they engage in sex work are extremely diverse. What they have in common is that they provide sexual services for money or other forms of payment. Worldwide, they are particularly exposed to stigmatization, violence and criminalization, which increases their vulnerability to HIV and other sexually transmitted infections (STIs).

The Study:

To date, there has been no study in Germany that deals with the health needs of sex workers, taking sufficient account of the group’s diversity in terms of gender identity and vulnerability factors. For this reason, the Deutsche Aidshilfe conducted a participatory research project from April 2022 to April 2024 with the aim of gaining a better understanding of the different needs of sex workers in relation to health, in particular HIV/STI prevention. The project was funded by the Federal Ministry of Health.

Ten peer researchers implemented eleven focus groups in five languages across Germany. A total of 80 female and male (cis and trans) sex workers took part in the focus groups, who worked in various contexts (street, escort, prostitution establishments) and came from 23 countries. Among them were women who use illegal drugs, Black women and people with disabilities and chronic illnesses. A special feature of the study is the high diversity of the sample. The openness of the study participants made it possible to obtain relevant results on a wide range of topics. The focus groups were analyzed using the qualitative content analysis method in a participatory process involving peer researchers and an interdisciplinary project advisory board.

Results:

The results of this study disproves the widespread public discourse dividing sex workers into “involuntary prostitutes” and “self-determined sex workers”. The study participants describe extremely complex and diverse feelings and attitudes towards their occupation and name both advantages and disadvantages. What they all have in common is that they talk about their occupation as work. Sex work is seen by many as a resource – it is the best or the only opportunity for them to earn money and thus secure their own livelihood and, in some cases, that of their families.

The needs that emerged from the various focus groups differ from one another. Overall, four core problems were identified that make the lives of many sex workers harder and have negative impacts on their health:

If sex workers are affected by one or more of these four core problems and the resulting challenges, they are less able to prioritize and to take sufficient care of their health.

Nevertheless, many participants in the study attach great importance to the topic of sexual health. They would like more information, particularly on HIV pre-exposure prophylaxis (PrEP), a drug-based method of protection against HIV, and on HIV post-exposure prophylaxis (PEP), an emergency measure to protect against HIV after a risk of transmission. Almost half of the respondents had never heard of PrEP before participating in the study, while a further proportion had only vague knowledge. PrEP appears to many participants in the study as a beneficial safer sex method and a possible professionalization measure. Various concerns about PrEP and taking medication in general were also widespread.

Many study participants have observed that there is an increasing demand for sex without condoms. Some describe how this trend, combined with the deterioration of their financial situation, puts them under pressure. This increases sex workers’ fear of becoming infected with HIV and STIs. Experiences with broken condoms and stealthing, as well as knowledge that condoms do not provide one hundred percent protection against STIs, contribute to this feeling.

Public health Departments (Öffentlicher Gesundheitdsdienst) play an important role in the sexual health of sex workers, in particular through the free and anonymous HIV/STI testing services in accordance with the Infection Protection Act (§ 19 Infektionsschutzgesetz). A key hurdle for many participating sex workers is a lack of health insurance. The results of the study underline the need to ensure that all people have access to health insurance and all people with HIV have access to HIV treatment. In order for sex workers to benefit from PrEP, it should be offered in more health authorities (Gesundheitsämter), for example on private prescription. To improve the health of sex workers structural changes are also necessary, which will increase their safety and opportunities for a self-determined life. This includes, on the one hand, the expansion of social work and counseling as well as the creation of spaces for peer-to-peer exchange among sex workers. On the other hand, prevention measures aimed at clients are needed – such as a campaign to promote respect, fair prices, the use of condoms and education on HIV/STIs.

The qualitative study of Deutsche Aidshilfe on the needs of sex workers in Germany has revealed serious problems and showed how sex work can be associated with health risks. The results highlight the need for great structural changes are needed in order to enable a safe, self-determined and healthy practice of sex work. In the following we present eleven recommendations. These were derived from the results of the focus groups and developed with the project advisory board and peer researchers.