A new multi-country study identifies maternity-related complications, and suicide, as the biggest mortality drivers among female sex workers. Published in Lancet eClinical Medicine, the research focuses on low and middle-income countries (LMICs), like India, Bangladesh, and South Africa. The scientists highlight that there is hardly any existing global research on sex worker mortality causes in these nations. In many of these countries, the researchers write, “civil registry and vital statistics data are often incomplete and (female sex workers) may not be identified as such in official registries”, hence “identifying causes of mortality…has proven challenging.”

Take the example of a sex worker from Andhra Pradesh, whose death from an accident went uninvestigated and unrecorded because a post-mortem doctor refused to come to office on a holiday. “When you’re a single woman and a sex worker who dies … nobody cares,” Priya*, a sex worker who was acquainted with the deceased, told The Swaddle.

It’s this systemic indifference that’s killing women like her — and a lack of any official record on the phenomenon belies any possibility of care or support, further pushing the epidemic into a shroud of silence.

To address these hurdles, the researchers adopted a method known as the Community Knowledge Approach (CKA). In cases where official data is incomplete or inadequate, CKA relies on information provided by community elders and other representatives who can provide a fuller, more detailed picture of the situation. Some earlier cases where researchers adopted CKA include assessing child drowning mortality in the Sundarbans, and estimating maternal mortality in rural Bangladesh.

On collating their data obtained through conversations and other CKA methods across eight countries and 2,112 female sex workers, the researchers observed that abortion was the single biggest cause of mortality, causing 33.5% of total deaths between 2014 and 2019. Further, other maternity-related complications resulted in 16.6% additional deaths. As a whole, then, maternity-related complications were responsible for more than half of the total deaths recorded by the researchers. Suicide, contributing to 13.6% of deaths, was the next biggest factor, followed by murder at 12.5%. HIV/AIDS caused 7.9% of deaths, while accidents made up for 3.2%. Causes for the remaining 11.6% of deaths remain unclassified.

Female sex workers (FSW) are among the most vulnerable population groups anywhere in the world. In most places, their work remains unrecognized and criminalized, leaving them susceptible to exploitation and harassment by their employers, clientele, and regulatory authorities; without much legal recourse. Since in several countries the profession remains taboo, they also remain socially ostracized. All of these factors also result in quality healthcare often being out of their reach.

As a result of social neglect, public health policies overlook them, and the lack of enough research leads to incorrect policies even when they may are centered around sex workers. For instance, sex workers are only recognized under the ambit of public health — or even as people — through the lens of AIDS control. But with the stats showing that HIV/AIDS is superseded by maternal mortality among female sex workers, it shows how sex workers’ rights as citizens are undermined due to the gaze with which the state views them. As such, there remain very few policies adequately address their healthcare needs correctly. The current study aims to guide public health officials and NGOs to properly identify mortality causes among sex workers so that they can meet their healthcare requirements.

The researchers in their study state that most existing data and studies on female sex worker health deal only with morbidity — or illnesses — and not mortality. “The findings of this study address a knowledge gap about causes of mortality among FSW and underscores the urgent need for country-specific programs to prevent FSW deaths,” they explain. Without an adequate idea about the causes of mortality, healthcare policies aimed at addressing female sex workers will remain incomplete and will fail to reduce mortality risks for this vulnerable population group.

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Among LMICs, a 2016 study on female sex workers in three Cambodian cities also observed abortion as the biggest reason for death in sex workers, causing 40% of the total mortality. Low bargaining power makes unintended pregnancies an almost inevitable outcome of sex work, as sex workers have disclosed. This, coupled with stigma and a lack of access to health services, leads to unsafe practices to induce abortions — with sometimes fatal consequences. The current study’s findings, then, emphasize how female sex workers in LMICs may suffer from similar issues across countries.

There are systemic exclusions at play. For instance, in India, most sex workers lack necessary documents like Aadhar, voter IDs, and ration cards. Without these documents, they can neither access social security schemes that they are in need of nor exercise their rights as equal citizens of the nation. This also prevents them from seeking quality affordable healthcare. When they are finally able to access healthcare avenues, they are either sexually violated by those in charge of protecting them, or they are turned away because of the stigma they carry due to their perceived association with HIV/AIDS and other sexually transmitted infections.

These injustices understandably also affect their mental health. A 2014 study on female sex workers in Goa observed that 19% of sex workers in the state had tried to die by suicide in that year. Intimate partner violence, violence by regular customers and others, and an overall deteriorating mental health were identified as key reasons driving them to attempt to die by suicide. In Israel, a study last year found that almost one-third of the sex workers in the country had attempted suicide, with close to 50% admitting to dealing with post-traumatic stress and other mental disorders. The current study’s findings also identify suicide and murder as the second and third largest drivers of mortality, highlighting the need for greater attention in recognizing the violence and social stigma that these professionals face.

The researchers identified some limitations to their study. They highlight, for instance, that their study was only conducted in some cities in eight countries. With a large, more diverse sample, some of the figures they arrived at could change. Further, they acknowledge that they could not cross-check or verify information obtained through CKA — carrying certain memory and recency biases — with either door-to-door individual surveys or with official data. The researchers, however, reiterate their confidence in the reliability of the CKA method as an economical, time-saving method to conduct large-scale, multi-country studies like theirs.

Moreover, the study points to mortality trends among cis women sex workers alone. But the sex worker community is vast and amorphously defined — it consists of trans women, men who have sex with men (MSMs), and other marginalized individuals who aren’t cis women. The focus on maternal mortality is significant and shows that there can be no homogenous approach to addressing the needs of the sex worker community — but there still remains a vacuum where trans sex workers’ reproductive health is concerned.

Nevertheless, the results of the study highlight the important role that safe sex practices and access to contraceptives can play a role in preventing mortality, especially in a vulnerable population group that may not be able to access the best healthcare and treatment opportunities. It emphasizes the need to have more conversations and for better education on contraceptives and safe sex among populations in these countries.