Survival, stigma and structural barriers: a qualitative study exploring the oral health experiences of women attending sex work support services in Liverpool

Aims Globally, sex workers experience significant oral health inequalities, including higher levels of dental decay, tooth loss, and trauma. Sex workers face intersecting challenges including homelessness, addiction, and stigma. In the UK, no qualitative research has explored the oral health experiences of sex workers. The aim of this research was to understand the oral health experiences and needs of women attending sex work services in Liverpool, to identify perceived barriers to care, and to explore acceptable approaches to improving services through participatory engagement. Methods A qualitative participatory study was conducted with adults with lived experience of using sex worker support services in Liverpool. Twenty-one semi-structured interviews were undertaken following opportunistic and snowball sampling through community support services. Interviews were analysed using a framework approach to generate inductive codes and themes. The themes were translated into professional illustrations which supported women to engage in the data co-interpretation process. Results Participants described lives shaped by violence, homelessness, and poly-substance use, with oral health positioned low within daily survival priorities. Drug use, high-sugar diets, xerostomia, vomiting, and disrupted self-care contributed to rapid dental deterioration. Poor oral health produced significant physical pain, impaired function, and profound shame linked to intersecting stigmas of sex work, addiction, and visible dental damage. Access to comprehensive National Health Service dental care was widely perceived as impossible; most care was urgent or self-managed, including DIY (do it yourself) dentistry. Despite this, women expressed strong motivation for restorative care and valued non-judgemental services. Conclusions Women who attended sex worker-specific support services in Liverpool experienced severe, intersecting oral health harms compounded by structural barriers to comprehensive rehabilitative oral care. Trauma-informed, flexible, and comprehensive dental services co-designed with women are required to reduce inequalities and stigma.