What Do Sex Workers Need For Their Health?

For two years, Deutsche Aidshilfe conducted a participatory qualitative study into 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 a total of 23 countries of origin. Among them were sex workers who use illegal drugs (prostitution to finance drug use), Black sex workers and sex workers with disabilities and chronic illnesses. A special feature of the study is the high diversity of the sample. The participants in the study were in different life situations and pursued sex work for different motivations. Their openness made it possible to obtain relevant results on a wide range of topics. The focus groups were evaluated 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 work 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 – in the sense that it is the best or only opportunity for them, to earn money and thus secure their own livelihood and, in some cases, that of their families.

The needs that came to light from the various focus groups differ from one another. Overall, four core problems emerge that can make the lives of sex workers more difficult and can have a negative impact on their health:

If one or more of these four core problems and the resulting challenges are at the forefront, sex workers are unable to prioritize and usually not take sufficient care to protect 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. Contributing to this feeling are experiences with broken condoms and stealthing – as well as knowledge that condoms do not provide one hundred percent protection against STIs.

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 Section 19 of the Infection Protection Act (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 more frequently in 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.

This qualitative study 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 make it clear how great structural changes are needed. The framework conditions urgently need to be improved in order to enable a safe, self-determined and healthy practice of sex work. In the following we present eleven recommendations below. These were derived from the results of the focus groups and developed with the project advisory board and peer researchers.