Introduction

Female Sex Workers (FSWs) face serious public health concerns [1] as they have high exposure to sexually transmitted infections (STIs) and Human Immunodeficiency Virus (HIV) due to recurrent high-risk sexual encounters. These include frequent sexual activity with multiple clients, inconsistent condom use, having sex under the influence of alcohol and drugs, and having sex for the first time at a younger age [2]. Furthermore, according to a meta-analysis of 14 studies examining HIV prevalence among FSWs in the US between 1987 and 2010, 688 of 3975 (17.3%) of FSWs were HIV positive compared to 0.16% of women in the general population [3]. For these reasons, FSWs have been described as a “core population” in STI/HIV transmission dynamics because HIV is endemic among FSWs and can be transmitted to the larger population from them [4]. A study on FSWs conducted in Baltimore, Maryland reported that 70 of 385 (28%) participants had at least one STI diagnosis [5], perhaps as the result of non-condom use and frequent high- risk sexual encounters. Additionally, the prevalence of STIs in the general population has continued to climb through 2019, reaching an all-time high for the sixth consecutive year, with 26 million new reported infections annually in the U.S. and costing approximately $16 billion in healthcare expenses [1].

Unprotected sex remains a major method of STI and HIV transmission. The male condom is the most effective method for preventing STI transmission during intercourse [1]. However, FSWs experience behavioral, interpersonal, financial, and environmental barriers to condom use. Behavioral factors, such as using alcohol and other drugs before sexual encounters, may reduce condom use as their cognitive effects impair decision making [2]. Furthermore, FSWs report greater histories of recent substance and alcohol use compared to women who do not sell sex [6], further increasing their susceptibility to condom nonuse. Interpersonal barriers include condom refusal from their clients and trusting that their regular clients do not have STIs [6]. Empirical research also indicates that consistent condom use is linked to healthy communication between sex partners; however, this sort of communication is less common in sex work [7]. Financially, FSWs who request that their clients use condoms risk large income losses because many clients prefer and will pay more for condomless sex [8, 9], and FSWs who insist on condom use despite this loss of income often face harassment from their male clients [4].

Other factors that influence the use or non-use of condoms are the venues and working conditions of FSWs. For instance, condom use among FSWs in developed countries, like the U.S. is higher in organized, indoor prostitution settings. The State of Nevada is unique in the U.S. in that it offers legalized, regulated sex work including enforcement of mandatory condom use to prospective clients and STI testing for FSWs in brothels before sexual activity, which has reduced the spread of HIV and STIs [10, 11]. In fact, there have not been any documented cases of HIV transmission in Nevada’s brothels since sex work was legalized [12]. However, in other areas where brothels are not legalized, HIV transmission is still very high among FSWs [13]. Research conducted in Nevada shows that FSWs operating in a legalized setting are better able to communicate and negotiate condom use with clients. Notably, legalized FSWs have safety mechanisms to protect them from physical violence such as intercoms in rooms which allow managers to listen to condom negotiations [14]. In contrast, street-based FSWs in Southern Nevada are nearly three and a half times less likely to use condoms with clients than sex workers who work in brothels [15]. Moreover, law enforcement personnel often harass, arrest, or extort sex from street-based FSWs who carry condoms [7]. As a result, street-based FSWs are less likely to carry condoms, and less able to negotiate for condom use with their clients [7, 15]. Hotel or brothel-based FSWs also tend to be better educated and have more money than street-based FSWs. Such financial and educational resources may afford greater knowledge of effective ways to prevent the transmission of HIV and other STIs among FSWs, and ways to empower FSWs to resist condomless sex with clients who offer more money for such activities [16]. Indeed, improvements in a FSW’s education level are associated with increases in their overall economic status, negotiation skill, and improved gender and power dynamics [17].

One of the Joint United Nations programs on HIV/AIDS (UNAIDS) strategies is the prevention or reduction of new HIV infections by 2030, and addressing barriers to condom use experienced by FSWs is key to accomplishing this goal. However, research on sex work in more developed countries, like the U.S., is scarce relative to research in developing countries [15]. Given the increased health risks sex workers face, and the dearth of research on this vulnerable group in U.S., the purpose of this study was to conduct a review on more recent empirical literature regarding the barriers to condom use experienced by FSWs. Findings gained from this review will help identify knowledge gaps, and guide future research, interventions, and policies to improve condom use among populations of FSWs.

Methods

Selection Criteria

We conducted this systematic review to identify barriers experienced by FSWs when negotiating condom use with their male clients. To be included in the review, articles were required to be peer reviewed, study FSWs, recruit participants in the U.S. or along the U.S border, present quantitative data, and be published in English. We chose to systematically review research on FSWs in the U.S. rather than doing a global review to limit variability of cultural and legal differences between countries. Studies examining U.S border cities were also included because thousands of families live, work, and socialize in the U.S. border region, many of whom have social, sexual, and family ties in both countries [18]. Because patterns of sexual behavior and attitudes change over time [19], we selected 2011 as a cutoff point in order to identify the most recent findings regarding barriers of condom use experienced by FSWs. We excluded studies that did not report original data (e.g., systematic reviews), studies conducted on male sex workers, studies conducted on transgender sex workers, and studies conducted outside of the U.S. or U.S. border. We limited our review to FSWs because male sex workers may have more control over whether or not they use a condom themselves. Similarly, studies on transgender FSWs were excluded due to the anatomical differences associated with condom use among transwomen who have not undergone gender confirmation surgery, which allows trans FSWs to control condom use during certain penetrative sexual acts which would not be possible for cisgender FSWs (i.e. acts in which the FSW penetrates their client). Articles meeting these criteria were included if they assessed or addressed inconsistent condom use or condom use barriers among FSWs. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines [20]. Articles were reviewed by title, abstract, and full text to confirm if the articles meet the selection criteria. Additionally, references from the systematic reviews identified during initial screening were examined and articles which appeared relevant were also screened for inclusion. Following the complete screening and review process, nine articles which met the inclusion criteria were included in the review (See Fig. 1).

Fig. 1
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Prisma Diagram

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Search Strategy

Literature was searched on five electronic databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane, Medline, and Psychology and Behavioral Sciences Collection (PsycInfo). PubMed and Medline yielded similar results. The population of interest was female sex workers in the U.S. without age, ethnicity, and race restrictions. Key search words and phrases were: (“condom OR condoms”) AND (“sex work”) OR (“sex worker”) OR (“transactional sex”) OR (“exchange sex”) OR (trade sex”) OR (prostitution”).

Article Screening and Data Extraction

The initial screening yielded 4879 articles. Filters were applied to include only studies which were: conducted within the U.S. or at the U.S. - Mexico border, written in English, published between 2011 and 2021, used a quantitative design, and peer reviewed. After applying these filters, 480 articles remained. Of these 480 articles, Zotero computer software identified and removed 215 duplicates, after which 265 articles remained. Using the PRISMA protocol, the remaining studies were further screened by two authors, resulting in the removal of 23 articles which were not relevant to the topic and 194 articles which described studies conducted outside of the U.S. The 48 remaining articles were further screened by examining the title, abstract, and full text by three authors. Of these, 38 articles were excluded by title and abstract, and 5 were removed during full text review due to other reasons. Thus, a total of five articles remained. Additionally, four more articles were identified from the reference lists of systematic reviews which had previously been screened for inclusion, resulting in a total of nine articles that met our inclusion criteria. Any disagreements regarding inclusion or exclusion of specific articles were discussed between the three authors and a consensus was reached based on the research question. The authors developed a data extraction form and extracted the following information from each study: year of publication, authors, study title, purpose of the study, research design, sample and setting, and results (see Table 1).

Table 1 Design, sample, setting, instruments, and findings of reviewed studies
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Assessment of Study Quality

The Joanna Briggs Institute (JBI) critical appraisal tool [21] was used to assess the quality and risk of bias of the included studies (see Appendix A). To ensure that articles included met quality standard, a cut off point for inclusion was set at 60% of the total questions that scored “yes” [22]. All nine articles included in the review met the cutoff point.

Results

Sample

Nine articles met our inclusion criteria after systematically searching, extracting, appraising, and synthesizing the evidence. Four of nine (44.4%) articles were cross sectional [7, 23,24,25]. Two more (22.2%) were quasi experimental [26, 27], an additional two (22.2%) were cohort studies [2, 5] and the remaining article (11.1%) described a randomized controlled trial [28].

Demographic Characteristics

Participants varied in their racial and ethnic identities. Two studies exclusively surveyed African American FSWs; three studies were majority White, but included participants of all races, two studies exclusively recruited Latina participants, and the remaining two studies were majority African American, but included participants from all races. All participants were FSWs who were at least fifteen years old. Sample sizes ranged from 68 to 1277. Seven studies were conducted in the U.S., and two studies were conducted in U.S. border cities. Of these two studies, the first examined participants in El Paso and Ciudad Juarez, while the second examined participants in San Diego and Tijuana (see Table 2 for demographic characteristics).

Table 2 Characteristics of selected studies
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Synthesis of Evidence

The analyses conducted on all nine studies identified reasons for inconsistent condom use among female sex workers. Across the nine studies, factors that influenced inconsistent condom use were alcohol and drug use, venue, socioeconomic status (SES) vulnerability, violence and gender power imbalances, regular client issues, and age.

Alcohol/ substance drug use

Five of the nine studies presented alcohol and drug use as a barrier to FSWs negotiating condom use. In these studies, the association between FSWs’ use of safer sex maintenance strategies and number of condomless vaginal/anal sex acts was weaker among FSWs who met criteria for hazardous drinking [7, 23–[24, 26]–27]. Furthermore, FSWs who have sex in exchange for drugs tend to develop a habit of consuming alcohol and using cocaine prior to sex acts [23, 26]. FSWs who have histories of childhood abuse were more likely to have serious mental health problems as adults, which may lead them to drink alcohol and misuse drugs, inhibiting their cognitive ability to negotiate for condom use [28]. Furthermore, having sex in exchange for drugs can lead FSWs to feel more comfortable and trusting towards their clients, which can result in them perceiving unprotected sex as less risky and decreases their odds of using a condom [22]. As a result, FSWs who exchange sex for drugs are over four times as likely to contract HIV compared to FSWs who traded sex for economic reasons [24].

Venue

One article reported venue as a barrier to consistent condom use [27]. The most frequently reported venues were indoor (brothels) or outdoor (streets). FSWs operating primarily indoors were significantly more likely to report consistent condom use with both steady and irregular clients. In contrast, street-based FSWs have more limited access to condoms than brothel based FSWs. Similarly, street-based FSWs often have non-permanent working locations, meaning that they are more likely to encounter unsafe working conditions and less likely to be able to effectively negotiate condom use as they move around and meet new, unknown clients. As a result, they face threats to their own safety and are more susceptible to physical abuse or a lack of payment for their services compared to their indoor counterparts, especially when they attempt to negotiate condom use [27].

SES vulnerability

Three articles identified poverty and cultural factors within communities as barriers to FSWs’ ability to negotiate for condom use [23,24,25]. The articles reported that some women engaged in sex work for necessities such as food, shelter, and financial resources for their dependents, while others traded sex for drugs. When compared to FSWs who have better socioeconomic status, FSWs who are experiencing poverty reported lower pay from their sex work. To make ends meet, FSWs in poverty tended to have more clients than higher socioeconomic status FSWs, which also resulted in more frequent condomless sex [23] Additionally, FSWs in poverty were also more likely to accept clients who offered to pay more money for unprotected sex than for sex with a condom [23,24,25].

Violence and gendered power imbalances

Gender and power issues also played a role in inconsistent condom use. Four studies reported that physical threats, abuse, and coercion were commonly directed at FSWs who tried to negotiate having sex with a condom [5, 7, 25, 28]. Furthermore, the ability to negotiate condom use is also compromised by gendered power dynamics. For instance, a male client with money has more power and control over a FSW in poverty as he is able to provide her with money, shelter, food, and other basic needs. Because of this, it is difficult for the FSW to turn down money to perform high risk sex acts, like condomless sex, and she will have less agency to escape her client if he abuses her. Thus, FSWs in poverty often accept condomless sex when physically threatened, when condom negotiations were rushed due to fear of the police involvement, or when they are offered more money than they would receive for performing protected sex [2, 7].

Regular client issues

Two articles [24, 27] reported that perceived familiarity with regular clients created trust and lowered a sense of urgency to negotiate for condom use. For instance, FSWs often assumed their regular clients were disease free and did not request to use condoms with those clients as a result. Such trust is more common among FSWs who traded sex for drugs as they often meet the same clients’ multiple times from social relationships among drug users [24].

Age

Three articles reported that age, coupled with experience in the sex work industry, was another barrier to condom use, although studies differed in the direction of this association [2, 5, 23]. FSWs who were younger or less experienced reported more frequent condomless sex, as they were more likely to be coerced, and less likely to be strong enough to resist physical violence or threats of violence from their male clients. Furthermore, younger FSWs were also less likely to set the terms of condom use before performing a sex act and were less able to identify strategies used to trick them in to condomless sex by their male clients. However, although FSWs with at least ten years of experience were more empowered to negotiate condom use, they often elected not to use the condoms so they could charge their clients more for their services [5, 28]. In support of this, one study indicated that younger FSWs are less likely to avoid condom use compared to older FSWs [2].

Discussion

Sex work has historically been a practice that, despite being largely disapproved of and usually illegal, is still widely present across the U.S. Given this, it is surprising that a relatively small number of studies about this population have been conducted in the U.S. Due to the U.S. Department of Health and Human Services’ objective to end the HIV epidemic and the importance of proper and consistent use of the male condom in preventing STI/HIV transmission [1], we conducted this systematic review to examine the barriers to condom use experienced by FSWs in the U.S. This review included nine peer reviewed articles published in English between 2011 and 2021 which recruited participants from the U.S. or from U.S. border cities.

Across studies, FSWs reported SES vulnerability as a primary motivator for engaging in sex work and as a primary barrier to condom negotiation. Notably, some participants reported insecurities regarding food and housing, while others traded sex for drugs. FSWs from minority populations were especially likely to experience SES vulnerability and to engage in risky sexual behavior at an early age to meet their basic needs due to systemic social and structural factors. As a result, minority women are more likely to be FSWs, experience more barriers to condom use, and are more vulnerable to HIV [32]. Moreover, minority women are often less educated than White women because of systemic racism [2, 5, 7, 23,24,25, 28] making them more likely to engage in sex work [32]. Such sentiments are echoed by The National AIDS/HIV strategy (2022–2025) report which recognizes racial disparities as a public health problem amid efforts to end the HIV epidemic [1]. These findings highlight the need to tailor interventions and policy changes to address existing disparities in wealth and education due to gender, race, and ethnicity. Doing so could not only empower FSWs to better negotiate and use condom during their sex work, but could also potentially prevent the need to engage in sex work in the first place.

A majority of the reviewed studies also found that alcohol and drug use was a barrier to condom use negotiation among FSWs. Consistent with a systematic review on condom negotiation [15], using alcohol alone or in combination with drugs before sex impaired FSWs’ decision making and limited their ability to fully evaluate the risks associated with condomless sex. As a result, FSWs were less likely to negotiate condom use when inebriated [7, 24,25,26]. Future research to learn more about the motivations behind FSWs’ alcohol/drug use is a viable option for informing prevention efforts. FSWs may drink alcohol for a variety of reasons, including to reduce the depression and stress related to their illegal, stigmatized, and sometimes demeaning work. Alcohol can also suppress feelings of hurt, guilt, and other negative emotions, reduce anxiety regarding FSWs’ sexual performance, enhance sex, and boost FSWs’ confidence with their clients [33, 34]. Additionally, alcohol consumption is required in some brothels or at the request of male clients [26]. For this reason, some FSWs may not wish to – or may be prohibited from – reducing their drinking, rendering alcohol use interventions ineffective. In such circumstances, alternative interventions to reduce HIV acquisition and transmission such as preexposure prophylaxis (PrEP) are of paramount importance. Although PrEP does not protect against pregnancy and other STIs [35], FSWs who are using PrEP would at least be protected against acquiring HIV in the event they are unable to effectively negotiate for condom use due to inebriation, coercion, or any other reason.

Likewise, FSWs in the reviewed studies reported that police officers can act as another barrier to condom use. For example, many police departments utilize repressive practices directed towards FSWs due to police misconceptions about condoms and sex work. Specifically, FSWs who possess condoms are more likely to be subjected to harassment, arrest, detainment, extortion, physical and sexual violence by the police [5, 7, 19]. For this reason, PrEP may particularly benefit street-based FSWs who typically have to rush or forgo condom negotiation with their clients for fear of arrests, or for FSWs who do not wish to carry condoms for fear of reprisal by the police.

Indeed, street-based FSWs appear to have significant condom use challenges, according to reviewed studies that compared condom negotiation barriers faced by FSWs who worked in either indoor vs. outdoor venues. Indoor FSWs were more likely to report consistent condom use with both steady and irregular clients than outdoor FSWs who are exposed when meeting and negotiating with clients. Outdoor FSWs also have no permanent working locations where they could store condoms for later use. Instead, they move around to avoid police officers and to meet new clients. As a result, they are less likely to negotiate for condom use, more likely to experience physical abuse, and less likely to be paid if they attempt to negotiate for condom use, relative to indoor FSWs [27].

As such, it appears that using Nevada as a model for legalizing and regulating indoor sex work may be an effective policy change for enabling FSWs to negotiate condom use and reducing HIV transmission. Not only have there has been no documented cases of HIV or AIDS transmission in brothels since legalization [12], but such legalized settings also provide FSWs with protections from violence, human trafficking, and non-paying patrons through access to security guards, panic buttons, and other resources which improve their safety. Such results could indicate that, if implemented at a nationwide scale, there could be a steep decline in the transmission of HIV through sex workers, resulting in a decline in the nation’s HIV epidemic.

Many reviewed articles also discussed the dynamics of gender and power imbalances. The power imbalance resulting from gender is evident in sex work as male clients tend to have more power which typically results in less condom use [29]. FSWs are more vulnerable to condom nonuse and its associated consequences than their male clients due to their status as women and as sex workers. For example, during sex, male clients don’t need approval from FSWs to use a condom, while FSWs who wish to use a condom are forced to negotiate with their male clients to get them to use one. Furthermore, cisgender women are more anatomically predisposed to STIs, HIV, and pregnancy during heterosexual intercourse than men are, meaning cisgender women have more to gain from using a condom, despite being less empowered to negotiate for their use [15]. Additionally, FSWs are often expected to be submissive to their male clients’ sexual desires and demands because of their status as women [30]. Such issues are further compounded by poverty, which is common among FSWs and results in a lack of self-efficacy to insist on condom use. Specifically, FSWs are often afraid to lose the financial support of their male clients if they refuse to pay or may feel unable to refuse additional payment for unprotected sex due to their low socio-economic status [31]. These findings highlight the need for interventions tailored for men to address gender-related disparities associated with condom refusal which emphasizes the importance of STIs and HIV transmission.

Limitations

Our findings should be considered with some limitations. For example, the self-reported sexual practices from the reviewed studies are subject to recall and social desirability biases which may limit their accuracy [36]. Namely, studies have shown that there is a discrepancy between self-reported rates of condom use and observed levels of unprotected sex [28], which likely occur because self-reports are prone to reporting biases. Additionally, performing a meta-analysis along with our systematic review would have increased the accuracy of the conclusions we drew from the pooled quantitative data we reviewed. Unfortunately, the significant variations in the designs of the reviewed articles made it infeasible to conduct such a meta-analysis in the current review. Likewise, four of the articles included in this review were identified via the citations of other articles, rather than through the database search, which may indicate that there are other articles which are eligible for inclusion which were not identified during the literature search. Also, eight of the reviewed articles recruited their participants through convenience sampling, which may have resulted in the participants from these studies not accurately representing the population of FSWs. Next, none of the reviewed studies described a priori calculation of the sample sizes. Finally, the findings of this review may be limited by their generalizability because only four of the fifty U.S. states (California, Texas, Maryland, and Florida) and two sites along the U.S. border were represented within this review.

Conclusion

This study highlights the barriers experience by FSWs during condom negotiations. These burdens increase the risk of unprotected sex, pregnancy, and STIs, including HIV, which may subsequently spread to other populations. Alcohol and drug use before and during sex, venues, SES, gender and power dynamics, client type, and age were all barriers to condom negotiation process among FSWs in this review. Outdoor venues appear to be especially high risk, as these workspaces have a greater potential to expose FSWs to abuse and condomless sex. More research that includes male and transgender sex workers is needed to fully understand the aforementioned factors and to identify other condom use barriers in these groups. Future directions could include increasing FSWs’ awareness of PrEP as an alternative to HIV prevention, as well as interventions that reinforce condom negotiation skills, provide safer venues, and regulate sex work, as all of these may help increase condom use and decrease STI transmission during sex work. Finally, male clients should also be targeted for interventions to enlighten them about the risks of condomless sex.