Systematic review of sexual violence against sex workers: implications for mental and sexual health

BACKGROUND: Sex workers worldwide experience different forms of violence and stigma that increase the risk of adverse health outcomes. It is assumed that a discriminatory, criminalizing context as well as intersectional stigma increases the risk of sexual violence for sex workers. We aim to answer the following questions: (1) What types of sexual violence do sex workers experience and (2) how frequently do they encounter it? (3) To what extent are these types of sexual violence associated with mental and sexual health conditions? (4) Are these associations moderated by legislative models? METHODS: In a preregistered systematic review (PROSPERO: CRD42024503922), scientific databases, references from meta-analyses, and publications from sex work organizations were searched. A total k = 207 quantitative and qualitative studies (N = 157,991) published since 2013 were summarized meta-analytically and narratively. RESULTS: Sex workers experience sexual violence across various contexts, with quantitative records identifying rape as the most prevalent form. Qualitative findings document varied forms of sexual violence including non-penetrative acts, sexual harassment, technology-facilitated sexual violence, and sexual neglect. The lifetime prevalence of sexual violence is 26.3% (95% Confidence Interval [CI] 22.0-31.0). Mental health conditions (depressive, post-traumatic stress symptoms, and suicidality) were associated with sexual violence: OR [95% CI] = 1.85 [1.58-2.16], p < .001, as were alcohol and other recreational drugs: OR [95% CI] = 1.95 [1.59-2.38], p < .001. Both sexually transmitted infections, including HIV (OR [95% CI] = 1.36 [1.11-1.66], p = .003) and reproductive health related outcomes (OR [95% CI] = 1.76 [1.18-2.63], p = .013) were significantly associated with sexual violence. Potential moderation by legislative model could not be detected due to insufficient data. CONCLUSION: This systematic review suggests sexual violence against sex workers as a critical human rights issue. However, the generalisability of these findings is constrained by substantial statistical heterogeneity and limited representativeness within the current literature, which remains focused predominantly on cisgender women in in-person sex work. This calls for redefining sexual violence with input by sex workers and addressing structural inequities to aid in destigmatizing sex work and reducing social inequities.