Current HIV prevention interventions for female sex workers (FSWs) have tended to target the cognitive factors in changing their behaviors, yet little attention has been paid to the psychological factors that influence the behavior of women in sex work. This review aimed to explore the associations between the psychological health of FSWs and HIV risk. A total of eight studies published in English before July 2013 were identified and reviewed. FSWs had reported psychological issues, including depression, suicidal thoughts as well as lower quality of life, and the pooled prevalence of probable depression was as high as 62.4%. The majority of studies showed that higher scores in psychological health problems were associated with increased HIV risk behavior, in particular inconsistent condom use, or sexually transmitted infections. Among the five studies which measured symptoms of depression, four documented that higher depression scores were significantly associated with inconsistent condom use among FSWs with their clients and/or partners. Meta-analysis using a fixed-effects model was performed to examine the association between depression and inconsistent condom use and found that higher scores in depression were significantly associated with inconsistent condom use (odds ratio = 2.57, p < .001). This review contends that future HIV preventive interventions should take psychological health of FSWs into consideration.

BackgroundEvidence shows traditional sexual harm reduction for female sex workers (FSW) based on health behaviour theories is effective but short-lived. This study aimed to evaluate and understand the effectiveness of a resilience-promoting programme in improving psychological health and, ultimately, safe sex practice.MethodsA randomised controlled trial was conducted at three Hong Kong-based non-governmental organisations. 127 sex workers were recruited and randomly assigned to the intervention or control groups. The former received a six-session resilience-promoting programme designed to improve self-esteem, self-efficacy and coping skills, whereas the latter had the usual care. Between-group differences in psychological outcomes and condom use were tested using the intention-to-treat, with ANOVA and chi-square tests, measured at baseline, post-intervention and 3-month follow-ups. Multiple mediation analysis was used to examine how the intervention worked through resilience factors.ResultsSignificant between-group improvements in adaptive coping (F1,119 = 5.82, p < .05) and reduction in psychological distress (F1,118 = 5.00, p < .05) were seen at post-intervention and 3-month follow-ups, with significant time × group interaction changes suggesting the changes occurred at different rates between the two groups. Condom use during the last transactions had increased in the intervention group and the rate of consistent condom use during transactions improved in the intervention group at follow-ups (χ2 = 4.35, p < .05). Self-esteem and resilience significantly mediated the effect of intervention at reducing psychological distress.ConclusionsThese findings suggest that resilience improves the psychological health and general wellbeing of Chinese FSWs.

The literature on positive psychology and resilience demonstrates that individuals utilize their personal strengths and environmental resources to facilitate positive adaptation. Using a qualitative approach, we investigated how these frameworks operated as self-protective strategies for female sex workers to maintain their psychological and physical well-being under stressful socioeconomic and work-related conditions. Twenty-three female sex workers in Hong Kong participated in in-depth interviews. We used the grounded theory approach for data analysis. The informants reported negative feelings in response to financial burden, clients' demands, threats to physical health, and stigma. Some female sex workers showed their resilience by being able to rationalize their role, believe their ability to make a change in life, and stay optimistic. They adopted strategies including emotional regulation and acceptance of their responsibility and limits to cope with stressful life events. The results help us understand the role of positive psychology and resilience in this vulnerable population.