COVID-19 COPING-PREVENTION STRATEGIES FOR FEMALE SEXUAL WORKERS IN THE CONTEXT OF VARIOUS COUNTRIESABSTRACT
Objective: to analyze the scientific evidence on COVID-19 coping and prevention strategies implemented to female sex workers in the context of several countries.
Methods: this is an integrative literature review, with data collected in the PubMed, Scopus, Virtual Health Library and Google Scholar databases using the Boolean descriptors “COVID-19” and “sex workers” and “Delivery of Health Care”, with a time frame from 2019 to 2020. A priori, 215 publications were found. After selection, anchored in the inclusion criteria and in the answer to the guiding question, 19 articles were used, whose information was organized in a synoptic table, and the texts were analyzed using semantic content.
Results: after content analysis of actions implemented or recommended in different countries, so that female sex workers can prevent contamination by Sars-CoV-2, four categories were highlighted: programmatic/governmental actions and responses from society; combating the stigmas involved in sex work; health education through technological/digital and media resources; adjustment of health services.
Conclusion: gender, race and class inequalities, as well as social stigmas, have been maintained by states governed by patriarchy and, therefore, are the main barriers for female sex workers to adopt strategies to combat COVID-19. Even so, intersectoral actions have been implemented/recommended in several countries such as the adjustment of sexual health services, financial incentives to improve the services of signal operators and digital technologies to implement effective actions to promote health education and enable the distribution of inputs for individual protection and prevention.
DESCRIPTORS: Coronavirus infections; Pandemics; Sex workers; Gender; Women’s health
RESUMEN
Objetivo: analizar la evidencia científica sobre las estrategias de afrontamiento y prevención del COVID-19 implementadas a las trabajadoras sexuales, en el contexto de varios países.
Métodos: revisión integradora de la literatura, con datos recopilados en las bases de datos PubMed, Scopus, Virtual Health Library y Google Scholar utilizando los descriptores booleanos “COVID-19” and “sex workers” and “Delivery of Health Care”, con un marco temporal de 2019 a 2020. A priori, se encontraron 215 publicaciones. Tras la selección, anclada en los criterios de inclusión y en la respuesta a la pregunta orientadora, se utilizaron 19 artículos, cuya información se organizó en la tabla sinóptica y los textos se analizaron a través del contenido semántico.
Resultados: luego del análisis de contenido de las acciones implementadas o recomendadas en diferentes países, para que las trabajadoras sexuales puedan prevenir la contaminación por Sars-CoV-2, se destacaron cuatro categorías: acciones programáticas/gubernamentales y respuestas de la sociedad; combatir los estigmas relacionados con el trabajo sexual; educación para la salud a través de recursos tecnológicos/digitales y mediáticos; reajuste de los servicios de salud.
Conclusión: las inequidades de género, raza y clase, así como los estigmas sociales, han sido mantenidos por estados gobernados por el patriarcado y, por lo tanto, son las principales barreras para que las trabajadoras sexuales adopten estrategias para enfrentar el COVID-19. Aun así, se han implementado/recomendado acciones intersectoriales en varios países como el reajuste de los servicios de salud sexual, incentivos financieros para mejorar los servicios de los operadores de señales y tecnologías digitales para implementar acciones efectivas que promuevan la educación en salud y permitan la distribución de insumos para la protección y prevención individual.
DESCRIPTORES: Infecciones por coronavirus; Pandemias; Trabajadores sexuales; Género; Salud de la mujer
RESUMO
Objetivo: analisar as evidências científicas sobre as estratégias de enfrentamento e prevenção à COVID-19 implementadas às trabalhadoras sexuais, no contexto de diversos países.
Métodos: revisão integrativa de literatura, com dados coletados nas bases PubMed, Scopus, Biblioteca Virtual em Saúde e Google Scholar usando os descritores booleanos “COVID-19” and “sex workers” and “Delivery of Health Care”, com recorte temporal de 2019 a 2020. Encontrou-se, a priori, 215 publicações. Após a seleção, ancorada nos critérios de inclusão e na resposta à pergunta norteadora, aproveitaram-se 19 artigos, cujas informações foram organizadas no quadro sinóptico e os textos analisados mediante o conteúdo semântico.
Resultados: após análise de conteúdo das ações implementadas ou recomendadas nos diversos países, para que as profissionais do sexo possam se prevenir da contaminação pelo SARS-Cov-2, foram evidenciadas quatro categorias: ações programáticas/governamentais e respostas da sociedade; combate aos estigmas envoltos do trabalho sexual; educação em saúde através de recursos tecnológicos/digitais e midiáticos; readequação dos serviços de saúde.
Conclusão: as iniquidades de gênero, raça e classe, bem como os estigmas sociais têm sido mantidas por Estados regidos pelo patriarcado e, por isso, são as principais barreiras para adoção de estratégias de enfrentamento à COVID-19 por parte das trabalhadoras sexuais. Ainda assim, ações intersetoriais foram implementadas/recomendadas em diversos países como a readequação dos serviços de saúde sexual, incentivos financeiros para melhoria dos serviços das operadoras de sinal e tecnologias digitais para implementação de ações efetivas à promoção da educação em saúde e possibilitar a distribuição de insumos para proteção e prevenção individual.
DESCRITORES: Infecções por coronavírus; Pandemias; Profissionais do sexo; Gênero; Saúde da mulher
INTRODUCTION
Coronavirus infection (SARS-CoV-2) and the resulting syndrome, coronavirus disease (COVID-19), was declared a pandemic in early 2020 by the World Health Organization (WHO) after its initial outbreak in Hubei province, in China, specifically in the city of Wuhan and the virus spreads quickly with high potential for contamination1-2. The virus’ characteristics led WHO to create rigid strategies for combating and advised that world governments implement them, with a view to preventing and controlling dissemination. The main guidelines were strict restrictions on the movement of the population on city streets and international or domestic travel, accompanied by border controls, social distance, wearing masks, as well as mass confinements, diagnostic testing and social isolation of infected people1-3.
This situation has favored the high mortality rate in groups of people who experience the invisibility of the State, as in developing countries. These countries have as their main characteristic the culture of patriarchy that makes governments perpetuate the social inequalities (gender, race, class, migratory), enhanced and wide open, in times when the planet experiences serious humanitarian crises, such as that of COVID-193-5.
In this context of invisibility and state neglect, women stand out, whose stigmas, social inequalities and disparities in gender, race and class (associated with sociodemographic aspects, low level of education), according to news reports, were accentuated on social networks and reports from organizations that are focused on surveillance and support. In addition to the female population in general, there are sex workers, who make up the group of vulnerable populations, whose social rights are denied themand have noticed, during the pandemic, a drop in the number of clients looking for their services and, thus, a decrease in income, so important for subsistence and needs4-6.
Moreover, another factor that constitutes a barrier to maintaining vulnerabilities and invisibility is that their work occupation is associated with sexuality and sexual practices as a way of obtaining profit, in which sex is offered as a service (which makes them suffer stigma, for breaking with the status quo of the behavior expected for women). Exchange of sex for money allows them to guarantee their livelihood and that of their families and, in this pandemic period, to be able to buy a mask, alcohol gel (among other hygiene and contamination prevention items) and food4-5,7-9.
Women who work in the sexual service have as a banner of struggle the need for recognition of the profession and the protection of the State, the guarantee of labor rights, security and protection against gender violence in its various aspects, respect for the service and the end of stigmas and prejudices (the latter, the greatest perpetuator of vulnerability, as it makes it difficult to protect the State and access sector services, such as health), something prevalent anywhere, such as Brazil, Malaysia and African countries4,7,10.
In this regard, the vulnerable situations that female sex workers are facing in the course of the coronavirus pandemic intensify as they continue to be helpless and ignored by the State, as with social isolation measures in Brazil and strict confinement in several countries (Italy, Spain, Argentina, China, and India),4,11-13 there was a reduction or absence of customers10-11.
The government of Argentine has supported female sex workers, providing them with some means of coping, granting the monthly aid of 5,000 pesos, equivalent to 500 reais11. Even so, they remain both without the regulation of the profession, and without access to the labor rights resulting from it, which is also present in Colombia and Brazil and in a more precarious way, since they did not have a specific basic income policy for them, despite the struggle of the Latin American Sex Workers Network and the Single Central of Sex Workers (Central Única das Trabalhadoras Sexuais)14-15.
This review is necessary for contributing to the understanding of how the COVID-19 pandemic manages to enhance the vulnerabilities of female sex workers. Thus, countruies’ governments can create and implement assistance strategies to promote health and human dignity (in the sphere of human rights) that allow this group of women to face this period of sanitary and humanitarian crisis, such as obtaining money to buy necessary basic products: food, hygiene products, mask, gel alcohol, in addition to being more exposed to SARS-CoV-2, for having to take to the streets in an attempt to find a customer.
It was designed as a guiding research question: what has scientific literature evidenced about the assistance strategies, implemented to female sex workers, in several countries, both in terms of coping and prevention, in the face of the COVID-19 pandemic? To assist in answering such questioning, this study aimed to analyze the scientific evidence on the strategies for coping and preventing COVID-19 implemented to female sex workers in the context of several countries.
METHOD
This is a study developed with the contribution of an integrative literature review, used to update or reach new knowledge, based on the following steps: theme desgintation; work plan outlining, with the choice of descriptors that suit the object; identification and location in the databases; coding and filing, with the construction of a table that presents the synthesis of results found (synoptic or synthetic table); decoding the data; inference of organized content; categorization of studies found; analysis with the aid of an analysis method for interpretation; interpretation of results and comparisons with other research16. It should be noted that in order to proceed with the integrative review, the guiding question was used to search for studies in the databases.
Even though this study is not a systematic review, it is an integrative review, the PRISMA resource was used through the adaptation of the checklist of 27 important items for review design, since it will assist in data collection of articles selected in databases and observation of main results. Furthermore, the four-step flowchart, indicated by PRISMA, was used for article identification, eligibility and inclusion17.
For data collection (which was paired and occurred between August and September 2020), the system integrated in the online databases of the Public Medical Literature Analysis and Retrieval System Online (PubMed), Scopus, Virtual Health Library (VHL) and Google Scholar was used with a view to reaching publications of scientific articles associated with the topic of study, with a time frame from 2019 to 2020 (this period was determined based on the beginning when the cases of COVID-19 started to appear in China), as shown in the flowchart (Figure 1). It is reiterated that it is possible to minimize possible biases in the stage of preparing the review when the scope of the research in several databases is broadened.
The use of the “integrated search method” adopted in the databases occurred with “all indexes” and “all sources”, in order to obtain an expanded and detailed search in titles, abstracts and texts. Using the Boolean descriptors “COVID-19” AND “sex workers” AND “Delivery of Health Care” made it possible to achieve 215 results (articles), considering the totality of the four databases (57 on PubMed, 23 on Scopus, 89 on VHL, and 46 on Google Scholar), being visible in Figure 1.
To do so, free and full-text filters were used, free of charge, in an article document format, in English and Brazilian Portuguese, with a 2019- and 2020-time frame. After reading titles and abstracts, 162 (12 on PubMed, 07 on Scopus, 34 on VHL, and 73 on Google Scholar) were excluded, due to duplicity, as well as due to resolutions and/or the summaries that pointed to an escape from the theme: they dealt with health professionals, HIV infections, mental disorders, sexual health and sexuality of other population segments.
A priori, since there was a new exclusion process, 53 studies were taken advantage of. After proceeding with an exhaustive reading of results and conclusions, the purpose of which was to check whether they answered the guiding question, 34 more articles were eliminated. Another reason for this last exclusion was the finding of duplicity in more than one database used in the collection, reaching the final number of 19 articles (Figure 1).
Detailed flowchart of the systematic selection of articles included in the study. PubMed, Scopus, VHL, and Google Scholar. Guanambi, BA, Brazil, 2020 (n=19).
It should be noted that for grouping the results, a synoptic table was built, in order to synthesize the most relevant information from the articles, as well as to facilitate the visualization of results, according to the compliance with the guiding question. The table contains the systematization of the main information: manuscript (with identification code), author (alphabetical order)/year, databases, study design and country involved or where the research was developed.
Subsequently, a semantic content analysis was performed, which allowed the interpretation of results, starting with text skimming and then a critical material reading. Then, we proceeded with the identification of similarities and divergences in the interpreted results, survey of the units of meaning and decoding of information, classification of the semantic similarities of the analyzed content, which enabled the evidence of the categories and, finally, favored the construction of inferences and interpretations18.
RESULTS
From the results found in the 19 articles included in this study, it was noticed that they were all published in English. According to the presentation of synoptic Table 1, of the total of articles, most, 36.8% (n=07), brought studies that addressed global issues; about 31.5% (n=6) spoke about Asian countries, two of which were about India; approximately 26.3% (n=5) addressed the African continent, three of which discussed female sex workers in Kenya. It is also noteworthy that European countries were portrayed in three studies at a global level. North-American female sex workers were named in one study. It should be noted that Latin American countries did not have any studies presented in the databases and were not mentioned (specifically) in the articles included.
Synoptic table with the characterization of articles collected on the PubMed, Scopus, VHL and Google Scholar databases, for the descriptors “COVID-19” AND “sex workers” AND “Delivery of Health Care”, from 2019 to 2020. Guanambi, BA, Brazil, 2020. (n=19)
It is noteworthy that for analysis of the semantic content of the results of the 19 articles, decoding the units of meaning was performed, through semantic similarities of the interpreted contents; subsequently, the four categories of analysis emerged, organized in a synoptic table, with the distribution of articles (according to the identification in the synoptic tables) that contributed to the composition of each one (Table 2).
Distribution of articles according to the identification of manuscripts in synoptic Table 2 for composition of analysis categories on “COVID-19” AND “sex workers” AND “Delivery of Health Care”, from 2019 to 2020. Guanambi, BA, Brazil, 2020. (n=19)
The category that obtained the highest number of articles used for the review was category one, in a total of 18 articles, followed by category four, with 16 articles. In turn, categories 2 and 3 were the ones that obtained the least number of use, both with 10 articles.
DISCUSSION
This review highlights the main intersectoral actions that some countries have developed to promote vulnerable populations’ health such as female sex workers. The findings of this study will help other countries to be encouraged to develop such government policies, as well as health professionals will be able to rethink their praxis, in a global and contextualized way from the adjustment of sexual health services for the screening of symptoms/combat COVID-19, promoted by the State. Moreover, the professionals who work in these services for screening and assisting social groups in situations of vulnerability will have the possibility to receive the demands of sex workers deepened during the pandemic, to distribute supplies for individual protection and prevention, thus encouraging and guiding the use of technologies and social media as resources for health education.
Discussion of results is systematized and developed, based on the four thematic categories, evidenced in the results and derived from exhaustive reading, semantic content analysis, interpretation, and inferences.
Programmatic/governmental actions and society responses
Governments have a responsibility to promote intersectoral actions, so that female sex workers are offered well-being or other forms of social support to guarantee income in all economic strata, since many families are codependent of the remuneration derived from sexual service4,8-9,14. This state protection, based on the increase in financial resources,19-21 in addition to impacting the economies for themselves to provide social protection, should guarantee the strengthening of the judiciary with other sectors of society, so that support networks are expanded and, there is less police coercion, whether physical or sexual22-23. Governments should encourage and guide positive policing and awareness practices that must be provided urgently4,10,12.
Public health initiatives are overcoming barriers to reaching vulnerable people, such as women who live on the sexual service, creating a favorable environment to support behavior change23-25. Another mechanism used and innovative in the response to COVID-19 includes structured community mobilization along with HIV prevention and adaptation of sexual health services to meet the demands of this group of women,26-28 like India and Singapore24-25.
The UK government is an example of support for vulnerable populations, as it provided the charity sector with £750 million (€855 million; $922 million) of funding to guarantee temporary/emergency housing and means of coping with COVID-19 of society29. Other governments have taken initiatives, such as Bangladesh, which is providing food packages for female sex workers; Thailand, the Netherlands and Japan are including female sex workers in emergency financial benefits30-31. These recommendations have been made by other studies27-28 as a way to maximize care and assistance articulatedly28,31.
African countries like Ethiopia and Kenya have faced difficulties in trying to implement such aid measures for sex workers, although there has been encouragement from support foundations or non-governmental organizations (NGOs)10,20,22-23. However, female sex workers who live in both developed and developing or poor countries face a harsh reality: the lack of regularization or recognition of paid sexual service as a profession20,26. In Canada, there is a discussion about C-36 (Protection of Exploited Communities and Persons Act), in an attempt to adjust and amend it, forbidding anyone to buy or advertise sexual services during the pandemic27,32.
Combating the stigmas involved in sex work
Due to the patriarchal cultural criminalization of sex work, both in Africa and in other developing or wealthy countries,4,20 associated with issues of intersectionality, which make workers even more vulnerable, since most of them make up the base of the social pyramid and are poor, black and from the outskirts28. Applying an intersectional lens can improve the understanding of the ways in which the stigma of COVID-19 crosses with gender, race, immigration status, housing security and health status, among other identities27,33.
Stigmas mean that female sex workers are not entitled to various social services and the safety net COVID-19. With the criminalization of sex work in several locations like Ethiopia, Kenya or Latin American countries, they are more exposed to punitive measures. Increased policing and curfew can expose them to more violence, abuse and harassment10,20,22,31. Some of them, who break social isolation, visit clients’ homes, being exposed to physical and sexual violence and do not receive payment as agreed22.
With the stigma and criminalization of trade in Africa, sex workers have often had their rights violated as a result of stigma, including limited access to the care offered by health services, legal services and the criminalization of all lifestyles4. The other levels of stigma and discrimination against sex workers can also make contact tracking a challenge and limit access to the COVID-19 test25,32-33.
It is necessary for governments to implement measures aimed at society and adjusting urban police services to deal with this problem. It is also essential that justice offices and police commissions develop and implement a strategy on how to protect, as has been done by NGOs in Ethiopia10 and in Canada,27,32 in an attempt to dialogue with representatives of the State. The situation worsens for workers who are migrants25,33 as in Canada itself, which has been arguing in an attempt to reform and amend legislation19,32 and Nigeria with the creation of an immediate firewall between health services and immigration authorities13.
The COVID-19 Global Humanitarian Response Plans emphasize the consideration of gender issues.22,31 Service can be in psychosocial support considering the intensification of stigmas in this pandemic. Campaigns to raise awaraness of society to deconstruct the stigmatizing narrative produced by the media, should be encouraged by governments19-20.
Health education through technological/digital and media resources
Health education strategies involve several concepts, intrinsic to the areas of health and education, which are symmetrical in terms of their purpose: to maximize people’s autonomy for the practice of self-care. In this sense, studies have been emphatic as to the relevance of using this tool for health promotion, both for prevention and for coping with COVID-19, especially in association with the media (radio, television, internet),4-10 as a way to reach, instrumentalize and empower these women - with knowledge, information, guidance13,22,33.
This discussion is consistent with the findings of several studies,24,27,31,33 which point to the tools that some governments used to dispense knowledge to female sex workers, such as the dissemination of information by health professionals who serve in health services and who have adapted to meet the demands of COVID-19,4 expanding access to cell phones and digital connectivity to expand access to information on preventing and combating COVID-19, as has been done in Ethiopia, in an attempt to break away from limited information about the pandemic that reaches the population experiencing economic poverty, in addition to the lack of cell phones and digital connectivity10.
Health education processes will show more effective and fruitful results when linked to intersectoral actions,24 as has been done by governments in developed countries: in North America (United States and Canada) and Europe, there has been an increase in income aid for access to technological means, expansion/improvement of internet service providers and operators of cell phones,19,21 incentive to virtual sexual service and consultations/gathering of vulnerable populations through the phone and virtual services (telemedicine)21,29.
Furthermore, health education consists of the best subterfuge, encouraged in some countries, such as Kenya, Canada and India, to protect migrant women in paid sexual service, by increasing culturally and linguistically accessible information about COVID-19 and how to protect themselves and protect others24,27,31,33. Other recommendations include regular communication with female sex worker community members by cell phone or WhatsApp groups22,24.
Adjustment of health services
States must equip themselves with a careful combination that favors the preparation of health systems, especially those of sexual health, as well as creating services for the screening of female sex workers,22,33 associated with increased awareness of frontline community services, organization of support services, screening and treatment of female sex workers who may develop COVID-1924-25.
Intersectionality in prevention, reception, intervention (disease prevention and health promotion) is essential to address various support services, such as psychosocial, including through social workers, with a view to detecting psycho-emotional stressors, often aggravated by the stigma surrounding the situation of these women and, for many, they are being exacerbated even more with COVID-1910,19-21,34.
Considering the expansion of such services due to the pandemic, which pointed to the health sector strangulation, this aggravation of global proportions also revealed another facet and reality, which demanded from states and governments, policies for the adjustment of services to combat respiratory syndrome due to the new Sars-CoV-2 coronavirus: maintaining the social invisibility of marginalized population segments23,35-36. Restructuring the public health system is imperative, with a view to the treatment of COVID-19 concomitant with STIs, already implemented in the United Kingdom29.
Thus, the limitations of this study lie in the types of studies included. Most were reflective, which made it difficult to verify what worked or not in the countries, since it did not present data/results from questionnaires or interviews as well as the cause and effect relationships between health and well-being measures and coping responses of female sex workers. Thus, this review points out in an integrated and organized manner the most efficient strategies that can be applied so that these women can protect themselves from COVID-19 and also have social/state support, which are the new and important aspects of the study.
It is suggested that further studies be carried out, with greater methodological rigor and a higher level of scientific evidence, to deepen the cause and effect relationships between the use of strategies in countries that are still formulating or are still in the process of implementing public policies for women, inserted in the paid sex market, during the COVID-19 pandemic.
CONCLUSION
In conclusion, among the prevention and coping strategies to be implemented to women sex workers, evidenced by scientific literature, the articulated governmental intersectoral actions stand out, for the reduction of stigmas, adjustment of sexual health services (Testing and Counseling Centers for STIs/AIDS) as a way to combat COVID-19 and make a joint approach to treatment for STIs, in addition to financial incentives to improve the services of signal operators, in order to have the efficient use of telephones and digital technologies that favor effective health education actions, for screening, guidance and capturing vulnerable groups in dispersion such as these women.
Social, cultural and gender inequalities, maintained in governments governed by patriarchy, make it difficult for female sex workers to adopt strategies to prevent and combat the pandemic, since this culture fosters the invisibility of women, especially those who experience sexual freedom and use paid sexual practice as work, such as sex workers.
Thus, political and social system are primarily responsible for enabling the protection of each of them, even though there is a lack of organization and support from the State in the protection and safety of sex workers, with conditions to performance social distance and isolation with dignity. This article contributed to the advancement of scientific knowledge, as literature survey provided subsidies for the implementation of actions to be developed by governments.
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Publication Dates
-
Publication in this collection
11 June 2021 -
Date of issue
2021
History
-
Received
20 Oct 2020 -
Accepted
13 Jan 2021
