Sex Clients Research Articles

Dynamics of Neisseria gonorrhoeae transmission among female sex workers and clients: A mathematical modeling study

BackgroundThis study aimed to examine the transmission dynamics of Neisseria gonorrhoeae (NG) in heterosexual sex work networks (HSWNs) and the impact of variation in sexual behavior and interventions on NG epidemiology. MethodsThe study employed an individual-based mathematical model to simulate NG transmission dynamics in sexual networks involving female sex workers (FSWs) and their clients, primarily focusing on the Middle East and North Africa region. A deterministic model was also used to describe NG transmission from clients to their spouses. ResultsNG epidemiology in HSWNs displays two distinct patterns. In the common low-partner-number HSWNs, a significant proportion of NG incidence occurs among FSWs, with NG prevalence 13 times higher among FSWs than clients, and three times higher among clients than their spouses. Interventions substantially reduce incidence. Increasing condom use from 10 % to 50 % lowers NG prevalence among FSWs, clients, and their spouses from 12.2 % to 6.4 %, 1.2 % to 0.5 %, and 0.4 % to 0.2 %, respectively. Increasing symptomatic treatment coverage among FSWs from 0 % to 100 % decreases prevalence from 10.6 % to 4.5 %, 0.8 % to 0.4 %, and 0.3 % to 0.1 %, respectively. Increasing asymptomatic treatment coverage among FSWs from 0 % to 50 % decreases prevalence from 8.2 % to 0.4 %, 0.6 % to 0.1 %, and 0.2 % to 0.0 %, respectively, with very low prevalence when coverage exceeds 50 %. In high-partner-number HSWNs, prevalence among FSWs saturates at a high level, and the vast majority of incidence occurs among clients and their spouses, with a limited impact of incremental increases in interventions. ConclusionNG epidemiology in HSWNs is typically a "fragile epidemiology" that is responsive to a range of interventions even if the interventions are incremental, partially efficacious, and only applied to FSWs.

Evidence-based prevalence of HIV infection and associated risk factors among female sex workers in Port Harcourt, Niger Delta, Nigeria

Human Immunodeficiency Virus (HIV) epidemic has remained a key public health issue for the sub-Saharan countries including Nigeria. Thus, sex workers in the region are top on the list of key populations with highest vulnerability. The prevalence of HIV among female sex workers is twice the prevalence found in the general population in Sub-Saharan countries. This study evaluated the prevalence of HIV among female sex workers in Port Harcourt, Rivers State, Nigeria. A respondent-oriented observational sampling technique which involved the use of questionnaire in addition to laboratory-based screening of HIV among female sex workers in Port Harcourt was used. The self-structured questionnaire comprehensively explored socio-demographic characteristics, and risk factors among the subjects. HIV rapid diagnostic test kit from Alere Determine was used to detect HIV infection. This cross sectional study findings recorded that, from a sample of 200 participants drawn, 171 were negative to HIV while 29 subjects were positive to HIV infection with an overall prevalence of 14.5% among female sex workers in Rivers State. Furthermore, the finding demonstrated null association (p>0.05) between HIV and the risk factors measured. The study implies that the risk of HIV among the study population, female sex workers, is not linked to the assumed risk factors measured in this study since the finding failed to establish association at p>0.05. HIV awareness campaigns should be intensified among female sex workers especially on the consistent and correct use of condoms, and possibly bringing HIV testing to the sex partners and clients as secondary prevention strategy to offset the trend in HIV prevalence among this key population. Also implementation of intervention such as HIV pre-exposure prophylaxis following crucial riskful accident; such as condom breakage is suggested among female sex workers.

Condomless Anal Sex Between Male Sex Workers and Clients in the Age of Hookup Apps.

Among men who have sex with men (MSM), those who also engage in the exchange of sex for money, drugs, shelter or other material goods (i.e., male sex workers-MSWs) have been found to have higher rates of condomless anal sex (CAS), HIV, and STIs than MSM who do not engage in exchange sex. To gain a better understanding of the factors that influence MSWs' engagement in CAS with male clients, we analyzed qualitative interview data from a diverse sample of 141 MSWs from 8 U.S. cities who met clients primarily through hookup or dating apps/websites and who reported having condomless anal sex with at least one of their exchange sex partners in the prior three months. While high client demand and financial incentives were the most frequently mentioned reasons for engaging in CAS with clients, other factors including drug and alcohol use, attraction to the client, the heat of the moment, concerns about sexual performance, and reliance on pre-exposure prophylaxis (PrEP) were also important. Participants who engaged in CAS generally felt that due to client characteristics or mitigating steps they had taken themselves, their chance of acquiring HIV/STIs was acceptably low. Hookup or dating apps/websites have provided an additional and increasingly popular venue for exchange sex to be arranged. These platforms also offer an opportunity for HIV/STI prevention through interventions and tailored messages delivered through these venues that address the motivations, misconceptions and/or situational factors that may lead to CAS.

Ethical intimacy: Relational work of male sex workers in Hong Kong

This article examines the boundary work of ethics in same-sex relationships between sex workers and clients in Hong Kong, a neoliberal cosmopolitan city that decriminalized homosexuality in 1991. Drawing on 11 months of ethnographic fieldwork between August 2019 and June 2020, I investigate the changing same-sex relationships between masseurs and clients in and outside gay massage parlors in Hong Kong. From in-house payment for sex to different off-premise gift exchanges, masseurs and clients transition from a market economy as sex workers and clients to the moral economy as real-life romantic and business partners. I build on Viviana Zelizer’s theory of relational work to examine how various forms of intersections of intimacy and economy are made ethical at different stages of masseur–client relationships. A historically contingent form of ethical intimacy emerges from the same-sex sexual economy as a queer response to socioeconomic inequalities in neoliberal Hong Kong.

What Sex Workers Do: Associations Between the Exchange of Sexual Services for Payment and Sexual Activities

This study investigates people’s associations between the exchange of sexual services for payment and different sexual activities. Sex work entails a range of activities, from in person services to online performances. To date, no study has asked about the activities individuals associate with the exchange of sexual services for payment. The relationship between the exchange of sexual services for payment and specific activities is an important area for inquiry, as there exists considerable variance in people’s views on sex work and associations are impacted by a range of attitudes. Using an original survey involving a substantial sample size of adults in the U.S. (n = 1,034), respondents are asked their level of association between the exchange of sexual services for payment and seven activities: pornographic photos, pornographic videos, webcamming, erotic dancing, erotic massages, oral sex, and sexual intercourse. The results reveal that respondents are more likely to associate the exchange of sexual services for payment with activities requiring in person and physical contact between sex workers and clients than non-physical activities. In addition, we find that conservatives are more likely to associate the exchange of sexual services for payment with non-physical activities than liberals. Moreover, we find that people who view the exchange of sexual services for payment as acceptable are more likely to recognize a broader range of activities as associated with such exchanges than are those who hold more negative attitudes. Views on acceptability are more important than are previous experiences of paying for sexual services. Our findings offer valuable insights for policymakers, researchers, and advocates seeking a comprehensive grasp of the complexities surrounding sex work in contemporary society.

Communicating Sex Work Online: A Content Analysis of Client and Provider Discourse in r/SexWorkers

ABSTRACT The growth of digital technologies has enabled the creation of online platforms for sex workers to share, create, and gather information. To elucidate how this community leverages social media, the current study analyzed how sex workers and related groups (e.g. clients) communicate in a pseudonymous online space – r/SexWorkers. A content analysis of 103 posts and 967 comments submitted to r/SexWorkers between March 13, 2021, and February 22, 2022 was performed, evaluating 1) the prevalence of risk (i.e. to sex workers and clients) within the community’s discourse, 2) types of information shared within the community (e.g. legal, health, and support), 3) features of information exchange (e.g. seeking and providing), and 4) the emergence and confrontation of stigma. The findings of this study indicate that users took specific interest in the risks sex workers face (as opposed to clients), providing information predominantly about economic and health concerns, discussing potential abuses, and providing support to one another. Moreover, while stigma was not commonly discussed by the community, users who did engage with stigma (especially professional stigma) sought to counteract prevailing beliefs about sex work. Accordingly, r/SexWorkers seemingly provides a beneficial online space for sex workers and clients to discuss risk, safety, and stigma.

Understanding the Impact of EU Prostitution Policies on Sex Workers: A Mixed Study Systematic Review

IntroductionThere is a growing interest in legislation and policies regarding sex work in the European Union and a debate between two opposite perspectives: prostitution is a form of gender violence or a work lacking legal and social recognition. This review aims to develop an integrative synthesis of literature regarding the impact of prostitution policies on sex workers’ health, safety, and living and working conditions across EU member states.MethodsA search conducted at the end of 2020 in bibliographic databases for quantitative, qualitative, and mixed methods peer-reviewed research, and grey literature published between 2000 and 2020 resulted in 1195 initial references eligible for inclusion. After applying the selection criteria, 30 records were included in the review. A basic convergent qualitative meta-integration approach to synthesis and integration was used. The systematic review is registered through PROSPERO (CRD42021236624).ResultsResearch shows multiple impacts on the health, safety, and living and working conditions of sex workers across the EU.ConclusionsEvidence demonstrates that criminalisation and regulation of any form of sex work had negative consequences on sex workers who live in the EU in terms of healthcare, prevalence and risk of contracting HIV and STIs, stigmatisation and discrimination, physical and sexual victimisation, and marginalisation due to marked social inequalities, for both nationals and migrants from outside the EU.Policy ImplicationsThe evidence available makes a strong case for removing any criminal laws and other forms of sanctioning sex workers, clients, and third parties, which are prevalent in the EU, and for decriminalisation. There is a need for structural changes in policing and legislation that focus on labour and legal rights, social and financial inequities, human rights, and stigma and discrimination to protect cis and transgender sex workers and ethnical minorities in greater commitment to reduce sex workers’ social inequalities, exclusion, and lack of institutional support. These measures could also positively impact reducing and monitoring human trafficking and exploitation.

A multi-country cross-sectional study to assess predictors of daily versus on-demand oral pre-exposure prophylaxis in youth from South Africa, Uganda and Zimbabwe.

IntroductionSub‐Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre‐exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on‐demand PrEP among AYP in South Africa, Uganda and Zimbabwe.MethodsA cross‐sectional survey was conducted in 2019 among 13‐ to 24‐year olds, capturing socio‐demographics, HIV risk behaviours and preferences for daily or on‐demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age.Results and discussionA total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17–22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on‐demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On‐demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18‐ to 24‐year‐olds vs. 47% in 13‐ to 15‐year‐olds). After adjusting for site, sex and age group, preference for on‐demand PrEP decreased as sex frequency over the past month increased (p‐trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on‐demand PrEP (p‐trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on‐demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on‐demand PrEP (p = 0.05).ConclusionsOur data show that AYP in four SSA communities prefer on‐demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio‐demographic differences and designed in conjunction with AYP.

Redefining the Mode of HIV Transmission through Analysis of Risk Attribution among the Reported HIV Cases from 1993 to 2021 in Bhutan.

Introduction The detailed risk assessment of the diagnosed HIV cases in Bhutan is an opportunity to carry out the risk analysis to generate evidence of wherein, under what context, and in which population groups most new infections are occurring. The evidence collected will help to test the current assumption of Bhutan experiencing diffused and generalized HIV epidemic. Methods This is a cross-sectional study using a quantitative method to assess the risk behavior of the diagnosed HIV cases from 1993 to 2019. The study also included secondary data analysis of those cases already captured by the routine case-based surveillance from 2020 to 2021. The data collection was done from 1 to 30 January 2022 in all the twenty districts of Bhutan. Descriptive statistical analysis was used to analyze the characteristics of the study population, and relationships were established using the Chi-square Test. We have sought ethics approval and obtained participants' informed consent. Results The risk attribution analysis showed that 81.94% of HIV infection among the reported HIV cases in Bhutan has occurred through high-risk heterosexuals and 8.88% through mother-to-child transmission, and parenteral transmission accounts for 1.58% and then 1.35% through homosexual. Of the 81.94% high-risk heterosexuals, 41.08% acquired through sex workers and clients of sex workers, 27.99% from HIV-infected persons, 12.64% from sex work, and 0.23% from injecting drug use. Conclusions This study has shed some light on a gradual epidemic shift from the current perceived diffused and generalized to the concentrated epidemic among subpopulation groups like female sex workers and their clients.

No increased HIV risk in general population near sex work sites: A nationally representative cross-sectional study in Zimbabwe.

ObjectivesSex work sites have been hypothesised to be at the root of the observed heterogeneity in HIV prevalence in sub‐Saharan Africa. We determined if proximity to sex work sites is associated with HIV prevalence among the general population in Zimbabwe, a country with one of the highest HIV prevalence in the world.MethodsIn this cross‐sectional study we use a unique combination of nationally representative geolocated individual‐level data from 16,121 adults (age 15–49 years) from 400 sample locations and the locations of 55 sex work sites throughout Zimbabwe; covering an estimated 95% of all female sex workers (FSWs). We calculated the shortest distance by road from each survey sample location to the nearest sex work site, for all sites and by type of sex work site, and conducted univariate and multivariate multilevel logistic regressions to determine the association between distance to sex work sites and HIV seropositivity, controlling for age, sex, male circumcision status, number of lifetime sex partners, being a FSW client or being a stable partner of an FSW client.ResultsWe found no significant association between HIV seroprevalence and proximity to the nearest sex work site among the general population in Zimbabwe, regardless of which type of site is closest (city site adjusted odds ratio [aOR] 1.010 [95% confidence interval {CI} 0.992–1.028]; economic growth point site aOR 0.982 [95% CI 0.962–1.002]; international site aOR 0.995 [95% CI 0.979–1.012]; seasonal site aOR 0.987 [95% CI 0.968–1.006] and transport site aOR 1.007 [95% CI 0.987–1.028]). Individual‐level indicators of sex work were significantly associated with HIV seropositivity: being an FSW client (aOR 1.445 [95% CI 1.188–1.745]); nine or more partners versus having one to three lifetime partners (aOR 2.072 [95% CI 1.654–2.596]).ConclusionsSex work sites do not seem to directly affect HIV prevalence among the general population in surrounding areas. Prevention and control interventions for HIV at these locations should primarily focus on sex workers and their clients, with special emphasis on including and retaining mobile sex workers and clients into services.

HIV incidence and impact of interventions among female sex workers and their clients in the Middle East and north Africa: a modelling study

SummaryBackgroundThe incidence of HIV infection among female sex workers and their clients in the Middle East and north Africa is not well known. We aimed to assess HIV incidence, the contribution of heterosexual sex work networks to these numbers, and the effect of interventions by use of mathematical modelling.MethodsIn this modelling study, we developed a novel, individual-based model to simulate HIV epidemic dynamics in heterosexual sex work networks. We applied this model to 12 countries in the Middle East and north Africa that had sufficient data to estimate incidence in 2020 and the impact of interventions by 2030 (Algeria, Bahrain, Djibouti, Iran, Libya, Morocco, Pakistan, Somalia, South Sudan, Sudan, Tunisia, and Yemen). Model-input parameters were provided through a systematic review of HIV prevalence, sexual and injecting behaviours, and risk group size estimates of female sex workers and clients. Model output was number of incident HIV infections under different modelling scenarios for each country. Summary statistics were generated on these model output scenarios.FindingsBased on the output of our model, we estimated a total of 14 604 (95% uncertainty interval [UI] CI 7929–31 819) new HIV infections in the 12 countries in 2020 among female sex workers, clients, and spouses, which constituted 28·1% of 51 995 total new cases in all adults in these 12 countries combined. Model-estimated number of new infections in 2020 in the 12 countries combined was 3471 (95% UI 1295–10 308) in female sex workers, 6416 (3144–14 223) in clients, and 4717 (3490–7288) in client spouses. Contribution of incidence in heterosexual sex work networks to total incidence varied widely, ranging from 3·3% in Pakistan to 71·8% in South Sudan and 72·7% in Djibouti. Incidence in heterosexual sex work networks was distributed roughly equally among female sex workers, clients, and client spouses. Estimated incidence rates among female sex workers per 1000 person-years ranged from 0·4 (95% UI 0·0–7·1) in Yemen to 34·3 (17·2–59·6) in South Sudan. In countries where HIV acquisition through injecting drug use creates substantial exposure for female sex workers who inject drugs, estimated incidence rates per 1000 person-years ranged from 5·1 (95% UI 0·0–35·1) in Iran to 45·8 (0·0–428·6) in Pakistan. The model output predicted that any of the programmed interventions would substantially reduce incidence. Even when a subpopulation did not benefit directly from an intervention, it benefited indirectly through reduction in onward transmission, and indirect impact was often half as large as the direct impact.InterpretationSubstantial HIV incidence occurs in heterosexual sex work networks across the Middle East and north Africa with client spouses being heavily affected, in addition to female sex workers and clients. Rapid scaling-up of comprehensive treatment and prevention services for female sex workers is urgently needed.FundingQatar National Research Fund (a member of Qatar Foundation), the Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medicine-Qatar, Qatar University-Marubeni, the UK Medical Research Council, and the UK Department for International Development.

The economics of sex work and major sporting events: Learning from the 2010 FIFA World Cup in South Africa.

Risk-taking in sex work is related to financial gains from condom-protected and condomless-acts alongside vulnerabilities, including socio-economic factors, which influence the safety of sex workers. Large international sporting events have been shown to significantly impact the economies of host countries, but there is a dearth of studies that examine how major sporting events may affect the economics of sex work and the risks taken by sex workers and clients. This study examines the determinants of the price of commercial sex alongside the price premium for and correlates of, condomless sex before, during and after the 2010 world cup in South Africa. We analysed data from three phases of repeated cross-sectional surveys with sex workers. Bivariate and multivariable logistic regression models were fitted to examine the predictors of condomless sex. We also fitted fixed-effect regression models to examine the determinants of the price of commercial sex across each survey phase. Findings suggest that the price of sex was higher during the world cup compared to before and after, whilst the price premium for condomless-sex increased from 36% before the world cup to 40% (p-value<0.001) and 57% (p-value<0.001) during and after the world cup, respectively. Across the survey phases, anal, oral or masturbation sex were more likely to be supplied without a condom compared to vaginal sex. The type of sex was the primary determinant of the price of sex across all phases. We show indicative evidence that the 2010 world cup was associated with an increase in the price of sex and supply of condomless-sex. Although these findings should be interpreted as associations rather than causal relationships, we recommend that countries with substantial sex-worker populations that host major events shouldexplicitly consider the context and structures of sex work, and promote client-focused safe-sex-interventions that explicitly consider the economic pressures faced by sexworkers to provide riskier acts, to minimise health impacts.

RETRACTED: A Markov model examining intervention effects on the HIV prevalence/ incidence amongst the overall population

Human Immunodeficiency Virus (HIV) remains a high burden in Africa. Several targeted prevention strategies are prevalent including the promotion of condom use, provision of anti-retroviral therapy (ART) and pre-exposure prophylaxis (PrEP). Optimal allocation of limited resources requires understanding how the HIV epidemic will be affected by these strategies. We develop a Markov model, considering four sub-populations: female sex workers (FSWs), general population (GP), sex clients (SCs), and men who have sex with men (MSM), which estimates the effects of these strategies on the HIV prevalence/incidence in Rwanda from 2017 to 2027. Using Rwanda's demographic, sexual risk behavior, and HIV-associated morbidity/mortality data, it was determined that by 2027, a 30% improvement in consistent condom use amongst female sex workers would reduce the HIV prevalence amongst female sex workers, sex clients, and the general population by 7.86%, 5.97%, and 0.17%, respectively. Secondly, while making improvements on the recurrent HIV testing as well as ART coverage only mildly reduces the prevalence/incidence amongst female sex workers, and sex clients, reducing the two would result in an increase in the HIV prevalence/incidence amongst FSWs and SCs. Lastly, our analysis shows that introduction of PrEP to female sex workers in 2019 is expected to reduce the HIV incidence amongst FSWs by 1.28% over the next decade. We further analyze scaling-up PrEP beyond the highest-risk population, i.e., FSWs, and weigh population-level impact with cost-effectiveness to make an informed priority-setting amongst women in the general population. We modeled the HIV risk to women, and computed the impact, cost, and cost-effectiveness of PrEP scale-up for younger women aged 15–25, women aged 25–34, and women aged 35–49 years, while accounting for the low program retention levels reported in demonstration projects. Perhaps, counter-intuitively, it is shown that PrEP could substantially avert more infections a year amongst women in the general population than amongst female sex workers. In summary, our models and analysis could help decision makers effectively allocate resources to each of these prevention/treatment strategies amongst different sub-populations.

The Economics of Sex Work and Major Sporting Events: Learning from the 2010 FIFA World Cup in South Africa

Risk-taking in sex work is related to financial gains from condom-protected and condomless-acts alongside vulnerabilities, including socio-economic factors, which influence the safety of sex workers. Large international sporting events have been shown to significantly impact the economies of host countries, but there is a dearth of studies that examine how major sporting events may affect the economics of sex work and the risks taken by sex workers and clients. This study examines the determinants of the price of commercial sex alongside the price premium for and correlates of, condomless sex before, during and after the 2010 world cup in South Africa. We analysed data from three phases of repeated cross-sectional surveys with sex workers. Bivariate and multivariable logistic regression models were fitted to examine the predictors of condomless sex. We also fitted fixed-effect regression models to examine the determinants of the price of commercial sex across each survey phase. Findings suggest that the price of sex was higher during the world cup compared to before and after, whilst the price premium for condomless-sex increased from 36% before the world cup to 40% (p-value<0.001) and 57% (p-value<0.001) during and after the world cup, respectively. Across the survey phases, anal, oral or masturbation sex were more likely to be supplied without a condom compared to vaginal sex. The type of sex was the primary determinant of the price of sex across all phases. We show indicative evidence that the 2010 world cup was associated with an increase in the price of sex and supply of condomless-sex. Although these findings should be interpreted as associations rather than causal relationships, we recommend that countries with substantial sex-worker populations that host major events should explicitly consider the context and structures of sex work, and promote client-focused safe-sex-interventions that explicitly consider the economic pressures faced by sex-workers to provide riskier acts, to minimise health impacts.

Predictors of Willingness to Diffuse PrEP Information within Ego-Centric Networks of Women Who Inject Drugs.

Little is known about how social networks among women who inject drugs (WWID) can be leveraged to increase awareness about pre-exposure prophylaxis (PrEP). We tested the hypothesis that interpersonal characteristics influence willingness of WWID to communicate PrEP information with peers. Forty WWID ≥ 18years completed social network surveys. Participants named on average 9.3 (SD = 3.3) network members, resulting in 375 unique relationships. WWID were willing to share PrEP information with 83% of network members. Participants had higher odds of willingness to share information within relationships when the network member was female, homeless and perceived to be at risk for HIV. Among relationships with family members and transactional sex clients, stronger emotional closeness was associated with higher odds of willingness to share information. Peer interventions where WWID share PrEP information with peers may be an efficient approach to increase PrEP awareness among this vulnerable population.

Mak Nyahs and Sex Reassignment Surgery – A Qualitative Study from Pahang, Malaysia

Introduction: Mak nyahs are locally known male-to-female transgenders in Malaysia. In Western countries, medicalization of transgenderism allows strictly selected patients to undergo sex reassignment surgery. However, a standardized treatment system is not yet available in Malaysia. A number of mak nyahs underwent sex reassignment surgery at their own will. This study aimed to explore mak nyahs’ knowledge and perception on sex reassignment surgery. Materials and Methods: A qualitative research was carried out from 13th July 2016 till 31st August 2016 among 8 adult mak nyahs in Kuantan, Pahang. Snowball sampling was used. Participants who gave verbal consent were interviewed individually and in focus groups. Data obtained was transcribed and used as the primary data source. Results: All informants were Malays and Muslims. They generally had some knowledge about the standard procedures and risks in sex reassignment surgery. All informants expressed their desire to have the surgery, but chose not to. Reasons discouraging them from having the surgery were: i) religion, ii) forbiddance from family, iii) fear of regret, iv) death from surgery, and v) the lack of necessity. Factors driving them to have the surgery: i) more income from sex work, ii) pressure from sex clients, iii) securing a stable relationship, iv) self-satisfaction, and v) hope for a better future. Conclusion: Religion seemed to be the main reason refraining them from undertaking the surgery. Counselling mak nyahs should include the advantages and disadvantages of sexual reassignment surgery. Islamic religious preaching is very important to help reduce high risk behaviours, as well as teaching mak nyahs to cope with challenges in adult life. Further research is necessary to show association between religious knowledge and successful rehabilitation of the mak nyahs’ community.

Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic

Despite awareness of the role of drug use in shaping sex worker/client interactions, these dynamics remain poorly understood in the context of illicit fentanyl-driven overdose epidemics. This study examined sex workers’ experiences negotiating client interactions amidst a toxic drug supply in Vancouver, Canada. Findings draw from two ethnographic studies. The first, conducted between December 2016 and May 2017, examined the rapid implementation of several low-threshold supervised consumption sites. The second investigated experiences of women accessing a women-only site from May 2017 to June 2018. Data included 200 hours of fieldwork and in-depth semi-structured interviews with 34 street-based sex workers who use illicit drugs. Data were analysed thematically with attention to the risk environment. Participants described providing harm reduction services to clients as a means to reduce overdose-related risks, thus increasing sex workers’ hidden labour. Participants, comments regarding criminalisation and stigma surrounding drug use and sex work indicated a reticence to report overdoses, thereby potentially increasing the risks of overdose-related harms, including death. There is an urgent need for sex worker-led overdose prevention strategies that prioritise health and safety of sex workers and their clients with specific attention to how the criminalisation of particular drugs, practices and people contributes to overdose-related risks.

Characterising the structure of the largest online commercial sex network in the UK: observational study with implications for STI prevention

This study analyses large-scale online data to examine the characteristics of a national commercial sex network of off-street female sex workers and their male clients to identify implications for public health policy and practice. We collected sexual contact information from the largest online community dedicated to reviewing sex workers’ services in the UK. We built the sexual network using reviews reported between January 2014 and December 2017. We then quantified network parameters using social network analysis measures. The network is composed of 6477 vertices with 59% of them concentred in a giant component clustered around London and Milton Keynes. We found minimal disassortative mixing by degree between sex workers and their clients, and that a few clients and sex workers are highly connected whilst the majority only have one or few sexual contacts. Finally, our simulation models suggested that prevention strategies targeting both sex workers and clients with high centrality scores are the most effective in reducing network connectedness and average closeness centrality scores, thus limiting the transmission of STIs.

Prevalence and incidence of HIV among female sex workers and their clients: modelling the potential effects of intervention in Rwanda

BackgroundRwanda has identified several targeted HIV prevention strategies, such as promotion of condom use and provision of antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP) for female sex workers (FSWs). Given...

Informal Strategies for Risk Assessment Among Brazilian Male Sex Workers and Their Clients

Sexually transmitted infections have always been a threat for both sex workers and their clients. This issue has become more prominent, however, since the early 1980s when HIV surfaced as an incurable and life-threatening virus. Studies on safer sex and male sex work have examined many topics but few studies have done so from the perspectives of both sex workers and their clients. In this article, we examine strategies used by both parties for risk assessments in Brazilian termas (saunas). We analyzed 45 in-depth interviews conducted between 2010 and 2014. All participants are or have been sex workers and or their clients. We used a grounded theory approach which allows themes and issues that participants deemed important to emerge in analyzing the data. The results of this exploratory study suggest that sex workers and their clients in Brazil attempt to make risk assessments even though their methods are not scientific or necessarily reliable. Three common strategies engaged by both parties include playing defensive, relying on visual verification, and using gossip as a source of information. In the absence of immediate and reliable source of information to aid risk assessment, these are some of the strategies they can use at the site of interaction to make their best informed decision on with whom to transact and what the transaction should entail. An often under-examined source of information is the role of gossips or small talk among clients, among sex workers and between sex workers and clients.