Understanding drivers of female sex workers' experiences of external/enacted and internalised stigma: findings from a cross-sectional community-centric national study in South Africa

To deepen our understanding of sex work stigma, and to its drivers and their interrelation, we conducted an analysis using structural equation modelling of the South African National Sex Worker Survey. We enrolled 3005 women in sex work using multi-stage sampling across all South Africa's provinces. Experience of external/enacted and internalised stigma was widespread. Non-partner rape, intimate partner violence and partner controlling behaviour (often expressions of external/enacted stigma) compounded internalised stigma. These experiences of violence, other manifestations of external/enacted stigma and food insecurity, were key drivers of internalised stigma, and often had an impact on mental health. We found that considerable protection against stigma emanated from viewing sex work positively. This resistance to stigma provided opportunities to shift the narrative. Reducing sex workers' exposure to external/enacted stigmatising behaviour, including by enabling more to work indoors, and providing greater protection from partner violence and rape, are critical for better health and well-being. Ending the criminalisation of sex work is foundational for safer working conditions and better health outcomes for sex workers, similarly providing adequately funded mental and physical health and social care through sex work specific programmes.

Automated summary

To understand the stigma surrounding sex work and its drivers, an analysis was conducted on the South African National Sex Worker Survey using structural equation modelling. The study found that external/enacted and internalized stigma were prevalent among sex workers. Experiences of violence, external/enacted stigma, and food insecurity were major drivers of internalized stigma, impacting mental health. However, perceiving sex work positively provided significant protection against stigma, offering opportunities to change the narrative. Reducing exposure to stigmatizing behavior, ensuring better protection against violence, and ending the criminalization of sex work are crucial for improving the health and well-being of sex workers through specific programs.