Introduction
Stigma and marginalization have a significant impact on the health of different societal groups and contribute to inequalities in healthcare (Hatzenbuehler et al. 2013). So far, sex work has barely been discussed within the context of medical ethics. However, it is increasingly recognized that the access of marginalized groups to healthcare is a vital issue for bioethics (Danis et al. 2016; Russell 2022). Consequently, this should position the healthcare needs of sex workers, who are a highly stigmatized group, as an important topic for medical ethics. International studies demonstrate that the social stigma associated with sex work is a key barrier to sex workers’ access to healthcare (Ma et al. 2017). This may be reinforced by stigma associated with sexually transmitted infections (STIs) and drug use (Benoit et al. 2018; Bungay and Casey 2019). Especially sex workers from marginalized social groups, including trans sex workers and racialized sex workers, may be affected by intersecting forms of discrimination and stigma1 (Oliveira 2018; Amnesty International 2023; Fisher et al. 2023).
On a policy level, four main approaches to sex work can be distinguished: criminalizing sex work and all those associated with it; criminalizing only buyers of sex work; legalization; and decriminalization (Mac and Smith 2018). In Germany, sex work is legalized. It is regulated by two laws: the Prostitution Act (Prostitutionsgesetz) established in 2002 and the Prostitutes Protection Act (Prostituiertenschutzgesetz), which came into force in 2017. The Prostitution Act changed the legal status of prostitution so that sex workers can now access social security in Germany, such as health and unemployment insurance. The Prostitutes Protection Act imposed stricter regulations on their working conditions. It now legally requires all sex workers to be registered with the respective authorities, with additional requirements for foreign citizens, who must prove that they are authorized to work in Germany. The law also requires sex workers to receive regular health counseling each year (every 6 months for sex workers under 21 years of age). In addition, it introduced new regulations for workplaces such as brothels which are intended to ensure the health and safety of sex workers, and allows unannounced inspections of these establishments (Eger and Fischer 2019). In practice, these regulations restrict sex workers’ agency, for instance by affecting sex workers who informally share working facilities. The Prostitutes Protection Act reflects how protecting sex workers’ safety, rather than their autonomy, plays a central role in the German discourse.
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Some healthcare services tailored to the needs of sex workers already exist in Germany.2 For example, in Bochum (North Rhine–Westphalia), sex workers can use health and counseling services provided by WIR-WALK IN RUHR, Center for Sexual Health and Medicine (WIR) and Madonna e. V., association for the promotion of professional and cultural education of sex workers. Madonna e. V. was founded in 1991 as a self-help initiative of sex workers, former sex workers, and women from other professions3. In cooperation with the city of Bochum, Madonna e. V. provides information and advice on health issues related to sex work. The WIR is a multiprofessional out-patient healthcare service based in Bochum which offers prevention, counseling, testing for, and treatment of sexually transmitted infections (STIs) (Potthoff et al. 2021).
So far, there are hardly any studies that examine sex workers’ experiences with accessing healthcare in Germany (Eger and Fischer 2019). In this study, we therefore decided to investigate the experiences of sex workers and counselors in the specific local setting in Bochum to provide a comprehensive account of a well-established network of services for sex workers. Given the empirical evidence on sex work stigma and its negative impact on healthcare access, we hypothesized, within the theoretical approach of an ideal vs. reality study according to Kon (2009), that sex workers would encounter various barriers to care in spite of established care structures. Thus, the study aims to identify barriers and needs with respect to healthcare for sex workers, and to gather practical advice on how to (further) improve healthcare access for sex workers, both from the perspective of sex workers and counselors4.
Methods
Design
We performed an exploratory interview study using a content analysis approach according to Kuckartz (2014). The study was approved by the Research Ethics Committee of the Medical Faculty of Ruhr University Bochum (Reg. No. 22-7577). It was conducted by members of an interdisciplinary research group on healthcare justice funded by the Global Young Faculty in cooperation with the WIR and supported by Madonna e. V.
Selection of participants
In order to gain insights into how local services in Bochum are experienced, we used a purposive sampling strategy to recruit participants who either work as counselors at Madonna e. V. and WIR or who use these services as sex workers. With respect to sex workers, the sampling aimed to cover a variety of backgrounds regarding workplace, age, language, and migration experience. For the counselors, we aimed at variability in terms of professional background, years of expertise, and current position. Study participants were recruited via leaflets distributed at WIR and Madonna e. V. which contained a description of the purpose of the study, the research team, the funding body, and information about the reimbursement for participation in the study (€ 50 for counselors and € 100 for sex workers). The flyers were available in German, English, Romanian, and Bulgarian. Individuals interested in participating in the study contacted the last author and received further information on the study via telephone. All study participants received further information in person and were given the opportunity to ask questions before giving written informed consent. The sex workers could choose to sign the consent forms with pseudonyms to ensure anonymity.
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Sample characteristics
Four counselors at WIR and Madonna e. V. who had experience working with sex workers participated in the study. They all identified as cis women and had 5.4 years of experience in their current position on average.
Three sex workers who all identified as cis women were interviewed. We interviewed sex workers with and without histories of migration from Eastern European countries. One interview was conducted with an interpreter. Their work settings included sauna clubs, brothels, and private apartments or visits to clients.
Data collection
The interviews were conducted between November 2022 and February 2023 in the facilities of WIR or Madonna e. V. by one or two members of the research team. The last author participated in all but one interview.
The interviews were conducted based on an interview guide, which was jointly developed by all authors, taking into consideration the interview guide used in a prior study with sex workers (Ma and Loke 2019), and handled flexibly. Feedback on the interview guide was obtained from counselors at Madonna e. V.
The interviews were recorded, transcribed and pseudonymized by a professional external transcription office, which signed a confidentiality agreement. After transcription, the audio files were deleted so that only the fully anonymized transcripts remain. In one case, the interview was documented by handwritten notes directly after the interview. Interviews lasted between 45 and 79 min.
Data analysis
Data were analyzed using MAXQDA (MAXQDA 22 Standard Portable, VERBI Software GmbH, Berlin, Germany). We performed a structuring qualitative content analysis according to Kuckartz (2014). The coding system was developed both deductively, based on prior literature searches and our hypotheses, and inductively, based on the content of the interviews. After an initial coding of one interview by two authors, the main categories were discussed by all authors. Subsequently, each interview was coded by two researchers who regularly discussed the main categories and subcategories. The first and last author reviewed all interviews, identified superordinate themes, and chose quotations that reflect the content of the respective categories. The results were presented and discussed at a public event at the Oval Office Bar in Bochum, an inclusive feminist space. The event was promoted via Madonna e. V. and the WIR. It was aimed at discussing the results with the interviewees, several of whom attended the event.
Researcher reflexivity
All authors are postdoctoral researchers: two medical ethicists with a background in medicine and philosophy who have received training in qualitative methods, two social and educational scientists with experience in qualitative research methods, and one neuropsychologist trained in working with patients in clinical and research settings, including semi-structured clinical interviews. Four of them are cis female, one cis male. All researchers are German and have no own history of migration.
Results
Four main topics were identified: (1) barriers to care, (2) mental health, (3) helpful structures, and (4) need for action. Selected quotations from the interviews were translated from German into English by the first and last author. Results emerging from one or several specific interviews are marked with the abbreviation for the respective interviewee (e.g., S3), where the letter C denotes counselors and the letter S sex workers.
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Barriers to care
Health insurance
Problems with the health insurance status of sex workers were mentioned in most interviews (C1, C2, C3, C4, and S3). Counselors reported that the health insurance system in Germany is highly complex and bureaucratic. A lack of knowledge about one’s own insurance status was described as an important barrier to accessing the German healthcare system (C1, C2, C4):
So that de facto most women don’t even know […] do I have insurance or not. Usually, we first have to find out whether they are somehow still insured in their home country. (C2)
In some cases, not knowing that one still has health insurance in one’s country of origin may lead to high insurance debts. Moreover, healthcare professionals’ lack of knowledge with respect to the European Health Insurance system could lead to treatment refusals (C2).
Additionally, many sex workers do not have health insurance, including those entitled to a European Health Insurance card (C2, C4). Some self-employed German sex workers are not health insured because the costs of insurance are too high. In these cases, high costs or uncertainty about costs of healthcare services may keep sex workers from accessing services (C1).
“Bureaucratic maze Germany”
The complex bureaucratic structures that organize access to health and social support in Germany were described as a central barrier to accessing healthcare (C1, C2, C4, S1). One counselor described this as the “bureaucratic maze Germany” (C1), with long and complex procedures to clarify and adapt sex workers’ legal and insurance status. This is especially problematic when sex workers are already suffering from health problems:
The main problem is that there is so much to do before you can take any of these paths. And women who are already that unwell usually can’t do that anymore, or only with very, very great difficulties. (C2)
Language barriers
Language was mentioned as an important barrier for migrant sex workers with no or limited German language skills due to the lack of free interpretation services. As one sex worker reports:
I went to a gynecologist […]. They said that my health insurance was not valid. Then I paid 150 euros. A week later a bill arrived. I went to the doctor’s office and because we couldn’t understand each other properly; they kicked me out. That’s why I had to take an interpreter with me. I paid 50 euros for that to solve my problem. (S3)
Bureaucratic barriers and language barriers may intersect and have negative consequences for sex workers, including disrespectful treatment and financial disadvantages. Non-German speaking sex workers were reported to be more likely to accept a treatment refusal even when they were entitled to medical care (C2). Sex workers would therefore go to doctors who speak their language or go to doctors in their country of origin (C3, C4, S3).
Mobility
Mobility was described as a barrier to medical care. Especially migrant sex workers were reported to move regularly, which makes long-term treatment provided by one medical center difficult (C3, C4). At the same time, counselors reported that migrant sex workers lack trust in German institutions (C2, C3, C4). Building a trustful relationship was described as a difficult task necessitating a lot of time, which may not be possible if sex workers do not stay in one place for long enough.
Stigmatization and discrimination in the healthcare system
Experiences of discrimination were discussed as one important barrier to healthcare by all study participants. While all counselors explicitly described different forms of discrimination faced by sex workers in healthcare, all sex workers first declined having experienced discrimination in healthcare, before reporting instances of discrimination that they would not describe as such. This discrepancy was noted by a counselor:
Sadly, I often have the experience with clients I know that they dismiss it. That they don’t see it as that bad; just because so many negative experiences have already been made that it’s just put up with. (C1)
Counselors reported that they had observed discriminatory treatment of sex workers in different healthcare settings due to the stigma associated with sex work (C1, C2, C3, C4), including the reproduction of negative stereotypes about sex work. One sex worker recounted that after telling her psychotherapist that her former abusive boyfriend had insulted her as a “slut”, her psychotherapist “confirmed” that she was a “slut” (S1). Discrimination—according to the counselors—operated through nonverbal cues such as longer waiting times, apparently talking about the sex worker behind their back and looking at them (C3), or through intrusive and voyeuristic questions about sex work that were medically irrelevant (C1). Additionally, doctors, such as gynecologists and general practitioners were reported to take sex workers’ complaints less seriously (C4). As a consequence, some sex workers decide not to disclose their profession to their doctors (S1, S3, C3, C4).
Study participants often mentioned gynecological and obstetric care in this context. For instance, it was described how a gynecologist reacted negatively as she determined a sex worker’s pregnancy, assuming that the child must be unwanted and from a client (C2). One counselor reported that she had identified her own biases when working with sex workers, such as expecting that they would be less sensitive with respect to intimate gynecological exams (C4). Additionally, assumptions about sex workers based on stereotypes were reported among obstetric care staff:
The questions that come then like, yeah: “Does she have any diseases? Is she addicted to drugs?” or something like that. Those are the first questions that are directly associated with that and of course they also ask […]: “Yes, is she [pregnant] from a john?”, […] “Are Child Protective Services involv- …?” So automatically there are these questions, which is of course discriminatory. (C4)
Counselors also explained that sex workers anticipate discrimination and negative healthcare experiences (C3, C4). This can lead to delayed service use:
But many at first don’t go to the doctor because they simply do not want to get into this predicament that they have to say that they are sex workers, which is why you’d rather not go to the doctor at all, only if you have to. (C4)
Sex work stigma intersected with racism, especially anti-Slavism5, in the context of healthcare encounters, such as abortion care (C1, C3, S1):
So in the area of […] abortions, I myself have already had that experience with a client […]. And the [staff member] from this […] clinic relatively explicitly made negative comments about the abortion. And but also, yes, like asked questions […] that clearly had racist tendencies. So the woman originally came from Bulgaria and the [staff member] kind of suggested that it’s common there, that many women would have abortions there […]; this attitude […] was very noticeable at that moment. (C1)
Many interviewees also stressed the bigger scope of problems encountered by migrant sex workers in Germany compared to sex workers without a history of migration, highlighting the extent of institutional and interpersonal anti-Slavism in Germany (C2, C3, C4).
Mental health
Mental health was a prominent theme in several interviews. One counselor suggested that mental health complaints are more common among sex workers than in the general population (C3). Two sex workers reported on their own histories of depression (S1, S2). All interviewed sex workers stressed that sex work itself did not cause mental distress for them (S1, S2, S3). In contrast, one sex worker explained that being self-employed and being able to work according to her own schedule was beneficial to her mental health (S2).
If sex work was identified as a risk factor for mental health complaints, it was mostly associated with working conditions, such as intense social contact or physically exhausting work (S2, C1, C2, C3). One sex worker considered involuntary sex work or financial dependence on pimps, which she had witnessed in other sex workers, as risk factors for mental health issues (S1). Poverty and financial difficulties, as opposed to sex work itself, were described as the main causes of mental distress in sex workers (S1, C1, C2), especially for migrant sex workers who provide for their family and children in their country of origin (C1, C2).
While mental health complaints seem to be relevant for many sex workers, sex workers were described as reluctant to seek mental health support. Counselors suggested that at least some sex workers did not take mental illness or distress seriously, or thought that it should be solved through social and practical changes, rather than professional support:
On the other hand, I have the impression that some women are not really aware […] that there is also a potential way to take care of your mental health […]. I feel like it’s not taken that seriously and like dismissed on your own. (C1)
As a consequence, counselors reported that sex workers only address mental health problems in severe cases, for example, when they are unable to work (C2), and one sex worker expressed that she did not believe in mental illnesses like depression (S3). The stigma around mental illness was suggested to deter sex workers from seeking mental health support (C2).
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Additionally, one counselor reported that mental healthcare professionals tend to exhibit stereotypes about sex work and may incorrectly focus on sex work as the sole cause of mental health issues:
[S]o most of them always complain that as soon as the topic sex work is brought up, it’s always just about that. And all psychological problems are reduced to sex work. And then very quickly they no longer feel heard. (C2)
Sex workers and counselors reported on a lack of tailored mental healthcare offers for sex workers (S1, S2, C1, C2, C3), as most healthcare offers that target sex workers are focused on STI prevention, testing, and treatment (S1, C1, C2, C4).
Helpful structures
All interviewees described a number of healthcare services tailored to the needs of sex workers in Bochum that they evaluated positively. Healthcare and social workers from Madonna e. V. and WIR regularly provide joint outreach services, including anonymous STI testing, providing free condoms, informing about contraception methods, and offering consultations for medical concerns (S1, C2, C3, C4). This outreach offer is commonly supported by professional interpretation services. These offers were described as helpful since they reduce various barriers to care, such as costs, mobility, health insurance status, and language barriers (C2). Sex workers were believed to increasingly trust counselors who regularly visit their workplaces (C2, C3, C4).
Sex workers and counselors reported that free healthcare services, such as hormonal contraception and treatment for STIs were of vital importance given the high percentage of sex workers with no or unclear health insurance in Germany (S1, S3, C1, C2, C3, C4). The interprofessional healthcare and social support offered across different institutions by WIR and Madonna e. V. in coordination with the local public health department (Gesundheitsamt), and other social and healthcare centers (such as Aidshilfe Bochum e. V.) were described as especially helpful and effective (S2, C4).
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While sex workers mostly supported the mandatory consultation with the local public health department prescribed by the German Prostitutes Protection Act, all reported that they did not receive any helpful information in the consultations, mainly because they were already aware of the information provided (S1, S2). This perception was supported by a counselor:
And these compulsory consultations are […] nonsense from a professional point of view, too. Because if a sex worker comes to me who has been working for ten years, which suggestions am I supposed to give her? That’s absolutely absurd. I just don’t know anything about the work. And everything I could tell her about it, she knows. […] [H]ow it’s going at the moment with the Protection Act, that misses […] its mark. (C3)
Need for action
Interviewees suggested that people who want to start sex work should be provided with free information and counseling about making sex work as safe as possible in the form of a “beginner’s guide” (C3, C4), including information about existing healthcare structures (S3). They stressed the need for anti-discrimination within healthcare services. This includes displaying accepting attitudes towards sex work that are not based on stereotypes (C3), and acquiring competencies on sex work and sex workers’ health needs. Structurally, more free healthcare offers for sex workers (C3), anonymous care, more healthcare offers with free professional interpreting (C2), and better access to health insurance (C4) were suggested. Additionally, it was mentioned that a re-evaluation of the Prostitutes Protection Act with a special concern for sex workers’ interests would be required (S2, C1, C3). Interviewees suggested that existing offers should be broadened to medical concerns beyond STIs (S1), and include psychological support (S1, S2, C3) as well as support for problems related to substance abuse (S1). Some participants discussed the option of open healthcare centers where sex workers would receive joint somatic and mental healthcare (S3, C3). Interviewees suggested that the existing outreach offers should be expanded, including outreach psychological support within brothels (S1, S2, C3).
Discussion
Our study provides first insights into the barriers and needs regarding sex workers’ access to healthcare from the perspective of sex workers and counselors in Germany. The results corroborate several topics already reported in research from outside of Germany, in particular the importance of stigma and discrimination, mental health, and the needs of sex workers.
Stigma and discrimination
Ma et al. (2017) have argued that the stigma associated with sex work is the most important barrier sex workers face with respect to accessing healthcare. Link and Phelan (2001) have conceptualized stigma as the reproduction of power relations, which does not only occur on the interpersonal level but is also embedded in social structures and institutions (i.e., structural stigma), or may be internalized or anticipated (Hatzenbuehler et al. 2013). As it can negatively affect the ability of stigmatized persons to access social resources, stigma is an important source of health inequalities (Jackson et al. 2007; Hatzenbuehler et al. 2013; Bowen and Bungay 2016) and may negatively impact mental health (Frost 2011; Benoit et al. 2018; Bungay and Casey 2019).
The stigma associated with sex work has been described as pervasive and affecting many parts of sex workers’ lives (Benoit et al. 2018; Weitzer 2018; Treloar et al. 2021). Many reports of discriminatory treatment and the perpetuation of sex work stigma by healthcare professionals on the interpersonal level exist. Qualitative studies with sex workers in different countries report descriptions of interactions with professionals where sex workers were treated disrespectfully (Benoit et al. 2018), refused treatment (Smith and Marshall 2007; Shaver et al. 2011; Scorgie et al. 2013; Bowen and Bungay 2016; Benoit et al. 2018), or where professionals framed sex workers as irresponsible or unable to take care of themselves (Bungay and Casey 2019). A recent German study shows levels of prejudice against sex work comparable to the general population among healthcare providers and demonstrates that providers overestimate the prevalence of mental illness and human immunodeficiency virus (HIV) among sex workers (Langenbach et al. 2023). Structural sex work stigma can refer to policies and laws which criminalize sex work (Ma et al. 2017; Benoit et al. 2018). Criminalization has detrimental effects on sex workers’ health: for example, studies demonstrate that the risk of contracting STIs and experiencing violence is higher when sex work is illegal (Decker et al. 2015). Internalized stigma can lead to sex workers perpetuating stigma themselves, for example, by trying to distance themselves from other sex workers who are particularly stigmatized, such as those who use drugs or engage in unprotected sex (Bowen and Bungay 2016; Carlson et al. 2017; Benoit et al. 2018; Treloar et al. 2021). Sex workers may also anticipate stigma, and the expectation of being discriminated against can deter them from accessing healthcare services, especially after having made negative experiences (King et al. 2013; Benoit et al. 2018; Ma and Loke 2019). Our findings support the prevalence of these different forms of stigma in the German context, although sex workers tended to downplay stigmatization. In line with our finding that sex workers did not categorize instances of what we understand to be discriminatory treatment as discrimination, Ma and Loke (2019) similarly report that sex workers sometimes do not perceive healthcare professionals’ stigmatizing attitudes as such.
The stigma associated with sex work can intersect with other stigmatized social categories, such as racial identity, migration status, gender identity, drug use, poverty, or social class (Bungay and Casey 2019). A recent focus group study demonstrates how groups such as Black female sex workers or trans migrant sex workers are affected by intersectional discrimination within the German healthcare system (Deutsche Aidshilfe 2024). Sex work stigma can also interact with stigma associated with specific reasons for seeking healthcare (Benoit et al. 2018; Bungay and Casey 2019), such as mental health conditions and drug use, STIs, or abortion. Our findings from interviews with sex workers as well as counselors demonstrate how sex work stigma intersects with anti-Slavism. This particularly affects sex workers from Eastern European countries, such as Romania and Bulgaria, who are working in Germany.
Other barriers to accessing healthcare reported in the literature include inadequate and inconvenient services for the specific needs of sex workers (Smith and Marshall 2007; Beattie et al. 2012; Varga 2012; Underhill et al. 2014) or a lack of adequate services (Smith and Marshall 2007), as well as a lack of information on available services (Basnyat 2017), which may be exacerbated by language barriers (Bungay and Casey 2019). Financial constraints (Ghimire et al. 2011; Beattie et al. 2012; Scorgie et al. 2013) and the costs of care (Smith and Marshall 2007; Varga 2012; Underhill et al. 2014) have also been reported as barriers to accessing healthcare (Ma et al. 2017). Our study suggests that sex workers in Bochum face similar barriers. Notably, central barriers such as lack of health insurance, navigating German bureaucracy, as well as language barriers, are particularly relevant for migrant sex workers.
Mental health
Previous studies indicate that there may be higher rates of mental health issues among sex workers (Martin-Romo et al. 2023), especially those who are socially and economically disadvantaged (Seib et al. 2009; Suresh et al. 2009; Rössler et al. 2010). This may, however, be influenced by convenience samples made up of primarily street-based sex workers. A study conducted in New South Wales, Australia, where sex work is largely decriminalized, contrarily showed similar rates of mental illness between sex workers and the general population (Donovan et al. 2012). A study that compared levels of burnout between female indoor sex workers and female healthcare workers in the Netherlands found that sex workers’ scores did not differ significantly from those of healthcare workers for two out of three measures of burnout (Vanwesenbeeck 2005). Sex workers and researchers have also criticized that research on mental health issues in sex workers often focuses on experiences of trauma and violence, demonstrating the common assumption that sex work is either chosen due to a personal history of trauma (Krumrei-Mancuso 2017) or that sex work itself is necessarily traumatic (Treloar et al. 2021).
In one qualitative study (Bungay and Casey 2019), participants identified mental health issues as sex workers’ primary health concern. Stigma, discrimination and the resulting social isolation can contribute to mental health issues (Bowen and Bungay 2016). Sex workers in an Australian study (Treloar et al. 2021) reported that having to lie about their work impacts their mental health more than the work itself. Studies also indicate that some sex workers regard the flexibility of sex work as an asset (Ma et al. 2017), especially for those needing to manage mental health issues (Treloar et al. 2021), which was also stated by one interviewee in the present study.
Stigmatizing beliefs about sex work can have particularly detrimental effects within mental healthcare. Mental healthcare workers may “essentialize” sex work by viewing a person’s identity as a sex worker as the single cause of mental health issues (Benoit et al. 2018; Bungay and Casey 2019; Treloar et al. 2021). Treloar et al. (2021) also report on sex workers’ experiences of mental healthcare professionals regarding sex work with fascination or voyeurism. Both of these aspects were reported by sex workers and counselors within our study. Such experiences of stigma and discrimination may significantly influence sex workers’ intentions of seeking mental health support in the future (Bungay and Casey 2019; Rayson and Alba 2019). In addition, our findings suggest that sex workers tend to downplay mental illness, which might partially be due to stigma surrounding mental illness.
Needs
In line with our findings, other studies have demonstrated that sex workers welcome services that are available, accessible, affordable (or free), confidential, and provide nonstigmatizing care (Ghimire et al. 2011; Beattie et al. 2012; Varga 2012; Underhill et al. 2014; Ma et al. 2017). Accordingly, both sex workers’ associations and relevant medical organizations recommend that health services for sex workers should be anonymous, voluntary, and nondiscriminatory. Such offers should be available in different languages and be accessible for sex workers without health insurance (Deutsche STI-Gesellschaft 2013; World Health Organization et al. 2013; European Sex Workers’ Rights Alliance 2023; Deutsche Aidshilfe 2024).
While STI testing is a common reason to seek healthcare for many sex workers (Bungay and Casey 2019), sex workers have multiple health needs beside STIs (Ma et al. 2017). Bungay and Casey (2019) have argued that a disproportionate level of attention and resources is directed towards STIs in relation to other important health needs. In particular, it has already been pointed out that sex workers need adequate mental health support (Ma et al. 2017; Bungay and Casey 2019; European Sex Workers’ Rights Alliance 2023). On the interpersonal level, our study corroborates the finding that a reduction of stigmatizing attitudes among healthcare professionals towards sex work is needed. For example, as suggested by Ma et al. (2017), sensitivity-training programs for professionals may be helpful to gain knowledge on sex workers’ needs and address existing biases. Sex workers should be involved in the development of such trainings (European Sex Workers’ Rights Alliance 2023).
With respect to German legislation, our findings suggest that the information provided in the mandatory counseling required by the Prostitutes Protection Act is not sufficiently helpful to most sex workers, a finding supported by the results of a short survey with counselors, employees of local public health departments, sex workers’ organizations and sex workers (Steffan et al. 2020). The majority of sex workers who participated in the mentioned survey reported that the mandatory counseling was not helpful for the actual realities of their work. Additionally, the survey indicates that the Prostitutes Protection Act had several negative effects on healthcare offers, including increased difficulties with providing outreach services (Steffan et al. 2020). The law is currently being re-evaluated by the German Federal Ministry for Family Affairs, Senior Citizens, Women and Youth, and a report to the German Bundestag is due in 2025 (BMFSJ 2023). Our study indicates that a re-evaluation of the law that gives priority to sex workers’ interests is necessary.
Limitations
Due to the nonrandom sample, the small sample size, and the study’s focus on the specific environment in Bochum, our study does not cover sex workers’ experiences in the wider German context. It focuses on cis women who work in brothels, sauna clubs, and similar settings, and thus does not reflect the healthcare needs of the diverse spectrum of sex workers in Germany. Also, our study does not reflect the various forms of racist discrimination that sex workers may experience within the German healthcare system. Furthermore, sex workers with high perceived language barriers, with a high level of mistrust of institutions or those living in particularly vulnerable socioeconomic conditions may not have considered participating. The study does, however, give insight into one specific local context, where a network of services tailored to sex workers already exist.
Conclusion
Our study demonstrates that sex workers experience the existing free, discrimination-sensitive, anonymous, and accessible healthcare services in Bochum as helpful. Yet, several barriers to accessing healthcare remain. On the interpersonal level, this includes the stigmatizing attitudes of healthcare professionals, and a lack of competencies regarding the healthcare needs of sex workers. On the structural level, adequate services beyond STI care are lacking, particularly with respect to mental health, and many obstacles are created by the complex bureaucratic structures in Germany. These barriers particularly affect migrant sex workers who have little knowledge of the German system. Future policy making and the development of additional services for sex workers should give priority to their perspectives and needs.
Acknowledgements
We would like to thank all interviewees for participating in the study. We would also like to extend our gratitude to Madonna e. V. and WIR for giving us advice on the study design as well as valuable feedback, and for supporting our research. We thank the Oval Office Bar collective for hosting our public event on the situation of sex workers in Bochum, Germany, and we thank the audience at this event for helpful feedback on our study results. We thank members of Madonna e. V., WIR, Berufsverband für erotische und sexuelle Dienstleistungen e. V., and the initiative Roter Stöckelschuh for valuable feedback on the manuscript.
Funding
The study was funded as part of the project “Global Young Faculty”, an initiative of Stiftung Mercator in cooperation with the University Alliance Ruhr coordinated by the Mercator Research Centre Ruhr in Essen. The program brings together young researchers from universities and nonuniversity research institutions based in the Ruhr area. The funding body played no role in the design of the study and collection, analysis, interpretation of data, and in writing the manuscript.
Declarations
Conflict of interest
M. Faissner, L. Beckmann, K. Freistein, J. Jungilligens and E. Braun declare that they have no competing interests.
Ethical standards
The study was approved by the Research Ethics Committee of the Medical Faculty of the Ruhr University Bochum (Reg. No. 22-7577). Informed consent was obtained from all study participants and all methods were carried out in accordance with relevant guidelines and regulations. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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