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School of Public Health
College of Health Sciences, Makerere University

It is time to address Sex Workers Mental Health Needs -Mak Researchers

Posted on : Wednesday, August 12, 2020

Depression Photo Credit; Medium

As countries maintain or adjust public health measures, legislation, and economic policies to reduce new HIV infections and thus achieve the ambitious UNAIDS goals of ending HIV/AIDS by 2030, there is an urgent need to protect the rights of, and to support, the most vulnerable members of society.

Latest research conducted among female sex workers has showed that the high prevalence of major depression is driven by psychological stress, living with HIV/AIDs, being verbally and physically abused by clients as well as being over 30 years of age.

A cross-sectional study conducted among 300 randomly selected female sex workers in Gulu district between march and June 2020 indicated that prevalence of major depression among the female sex workers in post-conflict Gulu district stood at 48 per cent compared to the overall depression levels in the general district population that was 25%. 

Dr. Simple Ouma, the lead researcher and a fellow at The AIDS Support Organization (TASO) observes that people living in conflict affected settings are more prone to major depression resulting their experience of traumatic life events and negative socioeconomic circumstances due to conflict. 

The researchers contend that the risk of major depression could be worst for female sex workers in Uganda since sex work is still an illegal practice and a prosecutable crime. 

"When treated promptly and effectively, many of the negative effects of depression on the lives and work of female sex workers can be averted. Our study was aimed at determining the prevalence and factors associated with major depression among female sex workers in post-conflict Gulu district so as to generate information necessary to inform appropriate interventions to reduce the burden," Dr. Ouma says. 

He adds that the illegal nature of sex work along the intolerable culture and religious beliefs in the country could easily lead to high level of stigma, Gender-based violence (GBV), and depression among female sex workers. 

Majority female sex workers resided in Gulu district
Majority female sex workers resided in Gulu district

Titled “Prevalence and factors associated with major depression among female sex workers in post-conflict Gulu district: a cross-sectional study,” researchers assessed the factors associated with depression.

Nazarius Mbona Tumwesigye, an Associate Professor at the MakSPH’s Department of Epidemiology and Biostatistics and the main mentor to Dr Ouma observes that the very high prevalence of depression calls for the Ugandan government through the Ministry of Health and the district health officers and the development partners to put more resources to address the mental health needs of sex workers in post-conflict Gulu and the rest of conflict affected settings in the countries.

Prevalence of Major Depression
Majority of the participants with Major Depression (50.4%) had severe depression 

Other researchers who contributed to this study include; Rawlance Ndejjo and Catherine Abbo. According to Dr. Ouma, since the high prevalence of major depression associated with risky sexual behaviour like condom-less sex and Gender-based violence, all stakeholders need to integrate mental health services for female sex workers with other health care services that target HIV prevention among this most at risk population.

For more than 20 years of the LRA insurgency in northern Uganda, Gulu district has been placed under peace recovery program that has according to researchers been rather slow and without meaningful economic resettlement package to individuals and families affected by the conflict.

This has left many individuals including the female sex workers struggling for survival. With an estimated 1425 female sex workers in Gulu, majority are said to live and work within Gulu municipality.

“It was noted that HIV-positive female sex workers were at increased odd of major depression. Therefore, there should be a special program to provide HIV counselling to this population in order to address HIV-related factors that put HIV-positive female sex workers at a higher risk of major depression,” says researchers in study report.

The study findings show that high prevalence of major depression has important public health consequences at individual and societal levels that require urgent attention of all stakeholders.

They recommend that any intervention to address major depression prevention, treatment and rehabilitation should target the older female sex workers especially those aged 30 years and above.

World over, depression is the leading cause of disability and a major contributor to the overall global burden of disease affecting more than 300 million people.


Major depression can cause disability and death through suicide as well as through worsening pre-existing physical illnesses. The known risk factors for depression in general population include biological factors such as chronic physical illness, experience of traumatic life events like rape, loss of loved ones, social adversity like extreme poverty and demographic factor for example being a female.

Among the female sex workers, risk factors for depression include experience of sexual, physical or psychological violence and psychological and physical burden of sex work itself.

Also, majority female sex workers are exposed to alcohol and illicit drug use, likely to cause physical illnesses and or problem that eventually lead to development of major depression.

Research has shown that suffering from major depression can lead to serious negative health and socio-economic impacts. Among sex workers, depressive symptoms can reduce one’s level of sexual satisfaction, while the use of anti-depressants can further lead to development or worsening of sexual dysfunction.

Researchers also observe that untreated major depression among female sex workers can hinder the progress made towards the prevention of HIV, other sexually transmitted infections and unwanted pregnancies may arise since the female sex workers with major depression are less likely to use condoms during sexual intercourse.

“Moreover, among the HIV positive female sex workers, major depression can lead to poor adherence to antiretroviral therapy, unsuppressed viral load and subsequent transmission of HIV infection to their clients and children,” argues Dr. Ouma.

Adding that; “HIV-negative female sex workers with major depression have diminished ability to negotiate for safe sex with their partners and can easily become victim of sexual violence like rape and other risky sexual behaviors.”  

During the study, the female sex workers were asked their reasons for joining sex work and majority (89.7%) mentioned poverty related reasons as their main driving force of whom 51% said they joined sex work to earn money for survival while 22% said they had been frustrated by financial hardship.

Meanwhile, 6.3% of the respondents said they join sex work because of widowhood or divorce that had robbed them of financial support from their husbands. At least 5.7% stated their parents/ guardians were not supportive, and 4.3% said they had joined sex work in order to look for school fees.

Majority of the participant female sex workers say they joined sex work to earn money for survival.

More information follow DOI:10.21203/


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