Introduction

Sex work is often defined as a consented exchange of sexual favors for money, goods or other benefits [1], and UNAIDS defines sex workers as women, men and transgender individuals who receive money or other remuneration in exchange for sexual favors weather regularly or occasionally [2]. Female Sex Workers (FSWs), for instance, represent a significant portion of this workforce and face unique challenges and societal perceptions. Their experiences often differ from those of their male and transgender counterparts due to various factors, such as societal attitudes, types of services offered, and specific vulnerabilities, including a higher risk of gender-based violence [1].

Throughout different communities, sex work can assume different forms and has different legal interpretations. In Africa, there are two contexts, one where sex work and related activities are considered illegal, and the second where sex work itself is not criminalized but solicitation of sex work in public is illegal [3]. The criminalization of sex work and the absence of policies to protect this group not only contribute to the violation of their rights but also increase the stigma and discrimination toward this population because it increases their vulnerability, which automatically affects their safety and health, as they are at high risk of contracting HIV [2, 4]. Evidence shows that a sex worker from a country where sex work is criminalized has a 7 times greater chance of having HIV when compared to a country where sex work is partially legalized [2].

Stigma plays an important role in discrimination, fueling social inequalities and causing victims to experience feelings of exclusion and depreciation [5]. The stigma surrounding FSW throughout the world comes from the negative perception that they are immoral and disease vectors [6, 7], causing them to be rejected by society [8]. Additionally, societal norms and cultural attitudes that view sex work as a deviation from traditional gender roles further exacerbate this stigma [9]. Such misconceptions not only marginalize FSWs but also create barriers to their access to healthcare, legal protection, and social acceptance, significantly impacting their quality of life and safety [9, 10]. This stigmatization often challenges the efforts being made to reduce the spread of HIV epidemics by increasing HIV status awareness [9–11].

Another critical factor that contributes to the vulnerability of FSW to HIV is physical and sexual violence, which often manifests as a direct result of the stigma directed toward this group, impacting the safety, health and quality of life of these women [12]. As a criminalized, stigmatized and marginalized group, FSW are more likely to experience violence while less likely to receive support when needed, either from the police or healthcare providers, hindering them from reporting incidents and allowing the violence cycle to repeat itself due to the impunity of the perpetrator [13].

Episodes of physical violence usually take place during the negotiations of the encounter, such as duration and condom use, and the likelihood of these negotiations escalating into violence is notably higher in situations involving drug and alcohol use [14]. Violence increases the vulnerability of FSW to HIV infection, as it hinders their access to information and services that can help protect them from HIV, impacting the progress of the ending HIV/AIDS epidemic as a public health threat by 2030 (8). Additionally, experiencing violence reduces the likelihood of FSWs seeking essential healthcare services following assaults, including post rape prophylaxis, HIV testing, and treatment for trauma [10, 14].

Despite Mozambique´s ranking among the nations with the highest HIV prevalence and new infections globally [15], there is a notable lack of research addressing the intersection of violence, stigma, and their impact on the HIV epidemic. A study among FSW of three provinces of Mozambique revealed that 11.1% out of the total participants were victims of physical violence in the six months prior to the survey [14], and another study among FSW showed that 70% of the respondents reported experiencing violence in the 12 months preceding the survey, where the primary perpetrators were clients, followed by police and law enforcement officers, and finally, healthcare professionals [10]. Aiming towards accomplishing the UNAIDS goals established for 2030 [16], comprehending the factors linked to the reporting of stigma and violence is crucial, especially considering their impact on the prevalence of HIV. This study is important because it will provide evidence on how stigma, physical violence and sexual violence burden the population of FSW as well as identify the factors associated with these issues, offering crucial insights to guide decision-making as precisely as possible.

Methods

Results

Sociodemographic description of FSW participants

A total of 2,567 FSWs participated in the survey. Among the respondents, 39.5% were aged 25 years or older, 71.4% had attained a secondary level of education, and 92.2% were of Mozambican nationality. Additionally, 69.2% identified as Christian, 61.0% reported being single or never married, and 71.2% relied exclusively on sex work as their primary source of income during the six months preceding the survey. The main sociodemographic characteristics are summarized in Table 1.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Unweighted pooled sociodemographic characteristics of FSW, 2019–2021.

https://doi.org/10.1371/journal.pone.0312550.t001

Experience of stigma among FSW

Overall, 24,7% of the surveyed FSW reported experiencing stigma related to their occupation within the six months prior to the survey. Mozambican FSWs were more likely to experience stigma (25.3%, p<0.001), as were those who were married or cohabiting (25.0%, p<0.001), those who had engaged in work other than sex work in the 6 months prior to the survey (26.4%, p<0.001), and those who had a higher monthly income from sex work (over 100 USD) (26.8%, p<0.001). Risky behaviors associated with a higher report of stigma included having two or more fixed partners (25.8%, p = 0.031), having more than three clients in the month prior to the survey (p<0.001), meeting partners through the internet/SMS (27.9%, p<0.001) and through an agent (27.5%, p<0.001), performing sex work in the partner’s car or house (30.8%, p<0.001), using nonprescribed drugs (31.9%, p<0.001), having symptoms or a diagnosis of an STI in the six months prior to the survey (31.9%, p<0.001) and HIV-positive results (23.5%). These associations are summarized in Table 2.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Weighted pooled sociodemographic and behavioral characteristics of FSW who experienced stigma, physical and sexual violence, Mozambique 2019–2020.

P-values were obtained from chi-square tests, which were used to explore the associations between participants’ background variables and the outcome variables.

https://doi.org/10.1371/journal.pone.0312550.t002

Correlates of stigma, physical and sexual violence among FSW

When analyzing potential confounders in the multiple regression analysis, FSW with secondary education or higher were more likely to experience stigma (AOR = 1.13, p = 0.047). The likelihood of reporting stigma also increased with the number of clients in the month prior to the survey, with FSWs having more than seven clients (AOR = 6.11, p<0.001). Additionally, FSWs who conducted sex work in their clients’ cars or homes (AOR = 1.33, p<0.001), those with hazardous drinking habits (AOR = 1.33, p<0.001), and those who had symptoms or STI diagnosis in last year (AOR = 2.28, p<0.001) had greater odds of reporting stigma (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Weighted multivariate logistic regression of factors associated with stigma and physical and sexual violence among FSW Mozambique, 2019–2020.

https://doi.org/10.1371/journal.pone.0312550.t003

FSWs with a secondary education level or higher (AOR = 1.13, p = 0.015), married/cohabiting (AOR = 1.49, p<0.001), who performed sex work in clients’ homes or cars (AOR = 1.51, p<0.001), with hazardous drinking (AOR = 1.17, p<0.01), who used unprescribed drugs (AOR = 2.29, p<0.001) and those who had symptoms or a diagnosis of an STI (AOR = 1.50, p<0.001) in the past 6 months before the survey had greater odds of reporting physical violence (Table 3).

There were greater odds of reporting violence among Mozambican FSWs (AOR = 1.69, p<0.001), married or cohabiting (AOR = 1.31, p = 0.003), those with more than seven clients in the last month before the survey (AOR = 1.47, p<0.001), those who engaged in street/park-based sex work (AOR = 1.31, p<0.001), those with hazardous drinking (AOR = 1.36, p<0.001), those who reported unprescribed drug use in the six months before the survey (AOR = 2.64, p<0.001), and those experiencing symptoms or a diagnosed STI during the same period (AOR = 2.12, p<0.001). Notably, HIV-positive FSW face higher odds of experiencing both physical (AOR = 1.15, p = 0.006) and sexual violence (AOR = 1.31, p<0.001) when compared to their HIV-negative counterparts.

Discussion

Our findings highlight significant levels of stigma, physical, and sexual violence among FSWs in Mozambique, with important implications for public health interventions. Stigma against FSWs remains a pervasive issue in the country, contributing to their vulnerability to HIV infection. Negative societal attitudes and discriminatory practices often restrict FSWs’ access to healthcare services and safer sexual practices [5, 9].There is a prevailing notion that FSW are perceived as immoral, indecent, disruptors of households, and potential vectors for diseases [9], and this negative connotation can significantly impact their healthcare seeking behavior, driven by the desire to avoid experiences of stigmatization, discrimination, and inadequate treatment [22, 23].

In our study, Stigma was notably higher among Mozambican FSWs compared to immigrant FSWs, likely due to the greater visibility of local FSWs within their communities, where they are recognized by family, friends, and acquaintances. In contrast, immigrant FSWs may face less scrutiny due to their outsider status. Societal attitudes often tend to tolerate outsiders’ behaviors while being more critical of similar behaviors among their own members [9]. Married or cohabiting FSWs also faced increased stigma, likely due to societal expectations that married women should not engage in sex work, especially considering their perceived roles as family role models [24].

FSWs who engaged in other jobs besides sex work reported higher stigma levels, possibly due to increased community interactions in these jobs, exposing them to more judgment. Those with higher incomes from sex work were also more stigmatized, likely due to the assumption that more clients and encounters increase visibility and exposure [9]. Alcohol consumption and nonprescribed drug use further intensified the stigma, as these behaviors are socially stigmatized and complicate access to health services [25]. Lastly, FSWs who self-reported an STI in the last 12 months experienced significantly increased stigma, as this may deter them from seeking medical care, exacerbating the cycle of stigma and risk [9].

In the context of sex work, violence often extends beyond the boundaries that separate different forms of violence and manifests collectively, leading to a convergence of physical, emotional, and sexual violence [14, 23]. The findings of this study reveal that over half of the FSW (52.3%) reported experiencing physical violence, and over one-third (37.9%) encountered sexual violence within the six months prior to the survey. Notably, clients, police, and friends commonly emerge as perpetrators in these incidents [14, 26].

Our study reveals that over half of the FSWs reported experiencing physical violence in the six months prior to the survey. Married or cohabiting FSW were found to have a higher likelihood of experiencing physical and sexual violence compared to their single or never married counterparts, contradicting previous research in Mozambique [14] where single FSWs were more frequently victimized. This difference could be attributed to domestic conflicts that arise when spouses discover their partner’s involvement in sex work, leading to violence due to feelings of shame or anger [14]. Furthermore, married FSWs may be more exposed and susceptible to both physical and sexual violence due to their lower likelihood of reporting abuse to avoid disclosing their engagement in sex work, thereby increasing their vulnerability [27]. Additionally, FSWs with a greater number of sexual partners, both regular and clients, reported higher rates of violence. Research from Mozambique and South Africa supports this trend, indicating an association between the number of partners and an increased risk of violence [14, 27]. Client-perpetrated violence often arises from disputes over sexual encounter negotiations or payment terms, and in the case of long-term relationships, it can be due to jealousy and possessiveness from the client [27]. Coercive and nonconsensual acts by clients, not agreed upon beforehand, are considered sexual violence [27].

Income derived from sex work also played a significant role in the risk of violence among FSW. Those with incomes exceeding $100 were at a higher risk of both physical and sexual violence compared to those with lower incomes. Higher incomes often indicate more clients and/or encounters, which may lead to demands for unsafe sexual practices, increasing the risks for FSWs [14]. Additionally, higher payments can limit their ability to negotiate safe practices during encounters, heightening vulnerability [10, 14]. Substance use, including unprescribed drugs and hazardous alcohol consumption, were associated with physical and sexual violence, particularly among women who consumed both substances. While substance use can serve as a coping mechanism within the sex work context, it reduces risk perception and impairs the ability to identify dangerous situations, ultimately increasing exposure to risky sexual behaviors and client aggression [9, 14, 27]. Moreover, the venue where FSWs meet their clients also significantly influences their risk of violence. Those who meet clients online or through SMS, as well as those who engage in encounters in street or park settings, face a heightened risk. Virtual interactions for client selection pose a risk, as they do not allow a pre-analysis of clients before the encounter [28], and street/park settings are usually associated with higher violence rates and are often located in areas with high alcohol consumption and elevated violence levels, creating an ideal scenario for physical and sexual aggression [10, 28].

Our study also revealed that higher levels of physical and sexual violence were reported by HIV-positive FSW (55.7% and 38.1%, respectively), and being HIV-positive was found to increase the chances of experiencing physical and sexual violence. Violence increases the risk of contracting HIV and other STIs. Studies show that women who experience violence are three times more likely to get HIV than those who do not [29]. This is because it hinders the negotiation of safe sexual conditions with clients, regular partners, or pimps, thereby increasing the risk of HIV infection [30]. The perpetrator of sexual violence is often characterized by no condom use, a high risk of HIV and other STIs, drug use, and aggressive action [4, 31]. This continuous cycle of violence prevents FSW from seeking justice services to report the assaults and accessing HIV prophylaxis healthcare services. Consequently, this directly impacts the growth of HIV cases and hinders the effectiveness of policies and interventions aimed at mitigating the epidemic’s growth.

Although our study provides valuable information about stigma and violence among FSW in Mozambique, some limitations need to be taken into account. First, the study lacks information about the perpetrators of violence, which makes it challenging to design tailored interventions. Second, the frequency of each type of violence is unspecified, making it difficult to distinguish between isolated incidents and recurrent patterns. Third, data on healthcare-seeking behavior among FSWs after experiencing violence are missing, which affects the assessment of service adequacy. Additionally, the study did not include high-class FSW, limiting our understanding of violence trends in higher socioeconomic contexts. Furthermore, the reliability of responses may be influenced by memory bias or discomfort in answering sensitive questions. Finally, it is important to note that the study’s findings may not be generalizable to other cities and provinces, underscoring the need for further research and a comprehensive approach to understanding violence against FSWS.

Conclusion

Our study highlights the high prevalence of self-reported stigma and violence (both physical and sexual) among FSWs in Mozambique. Stigma, often driven by societal norms, hinders safe sexual practices and healthcare-seeking behaviors. The coexistence of physical and sexual violence is alarming, with factors such as income, number of sexual partners, client acquisition methods, substance use, and STI symptoms contributing to the heightened vulnerability of FSWs. Additionally, being HIV-positive is associated with an increased likelihood of experiencing both physical and sexual violence, further complicating the challenges faced by this marginalized group.

Considering Mozambique’s high HIV prevalence, it is crucial to enhance public health responses that specifically target high-risk groups like FSWs. Establishing legal protections for FSWs and improving access to justice through dedicated platforms for reporting violence and rights violations are essential. Public health initiatives must prioritize reducing stigma, promoting safer sexual practices, and improving access to healthcare, particularly for FSWs who are most vulnerable due to income, client acquisition methods, and substance use. Tailored, multi-faceted approaches are necessary to create a safer and more equitable environment for FSWs in Mozambique.

Acknowledgments

The authors express gratitude to all the respondents without which the implementation of the study would not be possible. We also thank the individuals and entities involved in the planning, implementation, analysis, and dissemination of the BBS.