Sex Work, Transactional Sex, and Health Outcomes in the United States: A Scoping Review of Public Health and Biomedical Literature

Research on sex work and health in the United States remains limited and conceptually fragmented. There are two dominant analytical approaches to studying sex work in the public health and biomedical literature: studies that centre sex workers as the population of interest and examine health outcomes within this group, and studies that use a broader term, 'transactional sex', and treat it as a behavioural variable within a larger population of interest. A scoping review of public health and biomedical literature was conducted following PRISMA-ScR guidelines and established scoping review methodology. Three searches of PubMed were conducted yielding 21 included studies published between 2005 and 2025. Fifteen studies centred sex workers as the population of interest; six measured transactional sex as a behavioural variable within broader samples. Criminalisation, structural stigma, and policing emerged as dominant structural determinants across sex worker-centred studies. Population-based studies consistently identified economic instability and housing insecurity as precursors to transactional sex involvement. Many studies explored violence as a risk factor. Health outcomes were concentrated around HIV and STI risk, although some studies explored access to health services, reproductive care, and screening for IPV. This review proposes a conceptual framework to integrate these two ways of understanding how structural conditions, individual risk factors, transactional sex entry, and sex work-specific structural conditions form a broader system. Interventions including reconsideration of punitive legal frameworks and expansion of non-stigmatizing health and social services, are suggested alongside upstream investments in housing stability and economic support, to improve health outcomes for this population.