Systematic Review of Contraceptive Use Among Sex Workers in North America

To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making.

We searched PubMed, CINAHL, and Embase databases using the search terms "sex work(ers)," "transactional sex," "exchange sex," "prostitution," "contraception," "contraceptive agents," "birth control," "female," and "women."

Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria.

Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell's theory of gender and power as an analytic framework to further identify factors that limited reproductive agency.

Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion.

The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.