Results
Study participants
Interviews were held with female (106), male (26) and transgender (4) sex workers (see Table
1). Females in Zimbabwe were aged a mean 35.9 years, while other females were an average 28.4 years, similar across sites. Male and transgender participants were younger, with 63% of this group between 18 and 25 years. Participants had mostly entered the sex industry for economic survival, with women in Kenya beginning sex work as young as 17.6 years on average and men at 19 years, younger than mean sex work onset in Hillbrow (25.6 years) and Zimbabwe (26.6 years). All female participants interviewed in Kenya, Uganda and Zimbabwe had been born in their home country, though predominately they now worked outside the city of their birth. By contrast, around 60% of participants in South Africa, both in Hillbrow and the Limpopo province sites, and a quarter of the male and transgender sex workers, were cross-border migrants.
A variety of sex work settings were reported. Female participants in Hillbrow were overwhelmingly bar- and brothel-based, while street-based sex workers formed the largest group of participants in Kampala, Limpopo and Bulawayo. Once a client had been secured, participants across sites reported having sex in the ‘bush’, in a nearby lodge or hotel, at the client’s home, or at their own home.
Although many were driven to sell sex to escape severe poverty and unemployment, several sex workers reported that the work was attractive because it had given them financial independence and the ability to improve their economic circumstances. One participant saw it as an advantage that money from sex work “comes right there and then, unlike other jobs where the money will come late” (30 year old male, Bulawayo). Another stated: “I manage my own business – my money is not taxed” (34 year old female, Hillbrow). Many sex workers, especially women, used their income to support family members and pay school fees. The vast majority of women had children (94%, 100/106), and around a quarter had three or more (25/106). A few used money from sex work to create alternative income-earning ventures, such as buying sewing machines or additional land to rent, or opening a bar. A half to two thirds of women in Limpopo and Zimbabwe reported this, although in many instances these income sources appeared quite erratic. Under a third of women elsewhere and of males and transgender participants had alternative income.
For many of our participants, “exiting” sex work was not seen as a viable option, as many had limited education and thus few alternatives to earn income.
2 In South Africa and Kenya, a large proportion of female participants had completed secondary school (93% Hillbrow, 83% Limpopo and 81% Kenya). By contrast, most of the Ugandan (63%) and Zimbabwean (48%) women had only attended primary school. In short, despite its considerable drawbacks – as catalogued below – there are real advantages to engaging in this work that may not be available elsewhere, such as managing one’s own working hours, ready cash, earning higher wages than in other available employment [
16,
17] and being able to assert some measure of independence over one’s working environment.
Ownership and violence: client and sex worker interactions
The narratives of most of the sex workers we interviewed were dominated by descriptions of poor treatment at the hands of clients. A pattern emerged in which clients, by paying for sex, behaved as if they had full ‘ownership’ over the sex worker, and payment for services was seen to offer clients ‘carte blanche’ to do as they wish. This included ignoring sex workers when they made requests, for example, regarding condom use or preferred sex positions, or if they indicated they were in pain.
“You can tell the client to stop and he says, ‘didn’t I buy you with my money? I have to get my money’s worth first.’ For you don’t appear to him like a human being. So he mistreats you…when he leaves he may hit you on your face and it gets swollen.” (Female focus group, Kampala)
“A man came to me and approached me as a client, then we go to the bush and he sleep with me in a hard way. When I say ‘you are hurting me’, he said ‘I pay you, so don’t tell me shit.’” (25 year old female, Thohoyandou)
Clients also frequently tricked the sex worker into accepting a smaller payment or refused to pay for services at all:
“We meet clients who are so rough. Sometimes some pretend they want a short-time so when you are done, they refuse to pay.” (47 year old female, Bulawayo)
The illegal nature of sex work in all study sites was something that clients frequently took advantage of, using it to legitimate non-payment for services. This attitude was invoked even more readily with street-based sex workers, with illegal migrants and - in countries where same-sex relationships are criminalised (Kenya, Zimbabwe and Uganda) - with male and transgender sex workers:
“Sometimes a man will take you and after fucking, he says, ‘You are gay, where can you report me? I’m not paying you and you can do nothing about it.” (Male focus group, Kampala)
In all sites, virtually all sex workers reported being physically beaten by clients or threatened with firearms, with many having experienced this repeatedly. Several pointed out that accompanying a client to his home, as opposed to meeting him in a ‘neutral’ space, such as a room in a lodge or the sex worker’s own living space, increases their vulnerability to abuse. This principle was most evident in descriptions by both male and female sex workers of an alarming pattern of gang rape by clients. After agreeing to have sex with a client and arriving at the venue, there would be several other men waiting to have sex with them as well. A woman in Uganda related one such incident:
“A man can come and tell you that, ‘I want to spend a night with you.’ …So the man tells you that he stays alone; sometimes he even shows you the house keys and you go with him. When you reach there he opens the door and you enter or even you sleep with him and then he pretends as if he is going out to bath and there comes in others, like four of them and they all have sex with you.” (28 year old female, Kampala)
Having experienced several such incidents in the past, this participant asked one of the men “why do you do things like that?” His response revealed that the strategy was one commonly employed by poor men who could not afford to individually pay for the services of sex workers. He explained:
“We collect money amongst ourselves. So then one comes and negotiates with a woman and he takes you. After he finishes you he calls the rest of the others.” (cited by 28 year old female, Kampala)
This practice further illustrates the extent to which clients generally assume “ownership” of sex workers, objectifying them as a commodity that can be bought and then shared among friends.
Between a rock and hard place: criminal laws and police impunity
While gang rape perpetrated by clients was distressingly common, gang rape by police and related authorities was also reported across sites and in forms that were remarkably similar:
“There was this time when I was arrested by six policemen. They afterwards demanded sex from me. One of them threatened to stab me if I refused. I ended up having sex with all of them and the experience was so painful.” (26 year old male, Mombasa)
“They were policemen. There’s a car park next to the flat and they took me there and they took turns.” (26 year old female, Bulawayo)
Equally common was physical abuse by police, often taking extreme forms. Virtually all sex workers interviewed had experienced being beaten and assaulted by police at some point in their working lives.
“I remember when the riot police once picked us up, we were severely beaten, insulted and mocked by the police, I won’t forget that day. I was badly injured. My child asked what had happened to me and I had to lie and say I was attacked by robbers.” (48 year old female, Bulawayo)
With male and transgender sex workers, this police abuse often took on an added dimension of homophobia. A 29 year old transgender sex worker in Uganda recounted a particularly humiliating experience:
“They [the police] arrested me and undressed me and asked me whether I was a woman or man. They beat me and detained me in prison.”
Similarly, cross-border migrants also reported experiences of being singled out and denigrated by police – particularly in the two South African sites:
“Police are always complaining that we are not supposed to come here and do this business. They call us names – ‘makwerekwere’ (derogatory term for foreigner in South African slang). They arrested us and sprayed us with pepper spray inside… that big van. People were vomiting and coughing. Me, they sprayed into my eyes, saying ‘go back to your country.’” (36 year old female, Hillbrow)
About half the participants described being arrested by police, but frequently they were either released before arrival at the police station, or were taken there but not formally charged or detained. In the east African sites, however, some sex workers reported being arrested and detained for fairly long periods of time, ranging between one week and six months.
In all study sites, bribery, blackmail and sexual abuse by police was described as part-and-parcel of the daily working life of sex workers, a situation that was seen as being legitimised by the criminalisation of sex work. Many participants responded ‘all the time’ when asked “in the past year, have you been forced to pay bribes to the police or anyone else?” Unsurprisingly, routine police violations of the rights of sex workers, their lived experiences of criminalisation, and the consequent impunity of individual police officers from any form of punishment, have instilled a deep sense of futility among sex workers about being protected by the police or the value of reporting abuses to them. Most participants were adamant that they would not seek redress for the violations they had experienced.
“When a man rapes you, beats you or uses you, you cannot go and report him because you are a sex worker, though other people who are not sex workers can go and report. I just keep quiet and die with my pain… When you go to report you will be asked, ‘What were you doing?’ and you will be charged with prostitution, so the laws do not favour us and we cannot report cases.” (33 year old female, Kampala)
In the very few instances where sex workers had reported violations to the police, the response was usually negative and generated further trauma:
“The day I was raped I went to report to the police, but the harassment I got there almost made me faint. The police wanted me to explain every detail from the rape to the screams that I made. Another officer asked how a prostitute like me could be raped as I was used to all sizes. He told me in fact that man really spared me. He could have tested my ass too. He ended asking me if my ass is already opened. Never will I again go to report a case. I’d rather die.” (32 year old female, Mombasa)
Landlords, brothel managers and regular partners
While clients and police are perhaps the most visible role-players in the working environment of sex workers, a wide range of people, including landlords, hotel and bar staff, security guards and brothel owners, are either centrally involved in the sex trade or operate on its fringes. Our research found that these individuals frequently take advantage of sex workers’ vulnerable position and the illegality of sex work to extort money or sex.
“One day I was harassed by a client and when I told the bar manager he demanded sex so that he can help me. My landlord also demanded sex because I could not afford rent.” (25 year old female, Mombasa)
Indeed, landlords demanding sex in exchange for accommodation or basic services was a common experience across study sites, and particularly true for female sex workers who tended to live together in brothels or hotels (more so than male and transgender participants), and were therefore vulnerable to these sorts of demands. Just over a quarter of participants reported working from brothels; they recounted the fraught nature of negotiating terms with a brothel manager in a generally exploitative relationship:
“When you go with a client, the brothel manager takes 50% of your money. Since I am the one who toils for this money, I thought the manager would be taking a smaller percentage. Even when a client goes without paying me, I still have to pay the manager.” (26 year old female, Kampala)
More than a third of males (41%) and females (37%) reported having a regular partner. Most described these relationships as abusive, characterised by frequent verbal bullying, physical violence or rejection on account of their sex worker status, even if initially their profession had not seemed problematic to a new partner.
“My boyfriend harasses me because I am a sex worker and he demands sex, and if I refuse he rapes me. There was a time when he raped my child when I was at work. And I cannot get rid of him because if I try to chase him away he says that he will try his best to expose me.” (Female, 18 years, Mombasa)
Others had made deliberate decisions to eschew relationships with regular partners altogether, on account of these risks.
Our daily bread: abuse from family and community members
Many participants expressed fears of gossip and vilification by neighbours, and consequently tried to conceal their sex worker status from community members. Sex workers working on the streets, in particular, described being frequently shouted at by passers-by, laughed at, called names, and accused of ‘stealing men’ or of being HIV positive. A Limpopo-based participant explained the source of her neighbours’ deep suspicion of sex workers as stemming from fear that they would sleep with their husbands:
“Married women, they are a big problem. They hate us.” (Female focus group, Musina)
A Kenyan woman, aged 32, recalled an incident where these suspicions were acted out in a particularly humiliating way:
“One day I was at a club when a neighbour’s husband joined the table [where] I was seated. Someone saw us chatting and called his wife. The wife brought a few other neighbours and protested at the club. They beat me up and took me to the toilet. There, they pushed my head inside a dirty sink to drink the sewer. It was horrible. The husband ran, instead of telling them that we were not doing anything bad, just talking. Back at home, the landlord told me that I could no longer reside in his house as the women were furious with me because I would steal their husbands.”
As this example (and many others like it) suggests, it is difficult for female sex workers to forge bonds of solidarity with other women their communities. Women in these contexts are also easy targets of blame, with men for the most part being allowed to escape accountability for their actions. To counter this kind of treatment by neighbours and other community members, a Ugandan participant said that the sex workers she knew had made a deliberate decision to sell sex only to men from other neighbourhoods (female focus group, Kampala).
Some participants recalled being insulted in public by children, an especially painful affront, given that in many African communities it is a widespread social norm that children demonstrate respect for older generations. In Limpopo, a sex worker described how she had been taunted by children:
“It happens to me waiting for a taxi: small kids about 10-years old asking me to have sex, saying ‘I have 10 rand [about 75 pence].’ I refuse and they start to shout, ‘You sleep with our fathers at night!’” (Female focus group, Musina)
Common terms of abuse included: ‘bitch’, ‘whore’, ‘AIDS-man’, and insulting references to dogs:
[They say] ‘You’re just a prostitute and prostitutes are like dogs.’ (26 year old female, Kampala)
The notion that sex workers were not perceived to be “human” emerged strongly in all study sites, but particularly in east Africa.
“[People in the community say] I’m not a human being … I am just useless, spoilt and that’s the end of me. They can’t allow me to spoil others. When they see my child they say ‘that’s a prostitute’s child, look at it, child of a prostitute.’” (24 year old female, Kampala)
Aside from these more overt forms of stigmatisation and abuse, sex workers also reported being socially excluded by family, neighbours, and community members. Virtually all examples of social exclusion were provided by participants in the east African countries; Zimbabwean and South African participants tended to give less emphasis to this theme. If someone in the community hosted a party or organised a traditional ceremony, everyone would be invited, but women known to be sex workers would be deliberately overlooked. Similar discrimination even occurred in community-based initiatives, such as projects to support children orphaned by AIDS:
“We also have children whose fathers died, but we cannot go to those organisations for support. They say they cannot deal with sex workers; they want decent people.” (Female focus group, Kampala)
In Uganda, sex workers described being excluded from money-lending projects, even those dedicated to “developing women.” One explained:
“When a sex worker goes to them to ask for a loan so that she may start up a business which she will manage during the day, and at night go to do sex work so that she may pay back their money, they refuse, because she is a sex worker.” (Female focus group, Kampala)
Social stigma associated with sex work in this country was so all-encompassing, that it even negated the not-insubstantial social and financial contributions made by individual sex workers to their families and communities. In the following exchange, a 32 year-old Ugandan sex worker expresses her frustration with this situation:
“I still have a challenge with the people in the community. People we live with, they don’t want to associate with us. If you give them all you can, they only keep on saying ‘you are a prostitute,’ no matter what good things you do for them. My whole family depends on me alone, even when a person in my family dies, I have to meet all the expenses. Yet people still call me a prostitute.”
Several participants had been expelled from their homes by parents, other family members or community leaders, on account of the work they do:
“My family threatens me. One time I was chased from home after they realised what I was doing, being a sex worker and a male and I stayed away for some time.” (25 year old male, Kampala)
As this last participant intimates, for male sex workers there is often a double stigma attached to being involved in sex work and being identified as gay. Similar experiences of stigmatisation and ostracism were reported by a 26-year old transgender sex worker in Mombasa:
“Muslim elders and the community at large… they threatened to stone me to death if I go back there [home]. Now I keep a distance from my village and my people.”
This sex worker’s experience of being ostracised by religious elders was not uncommon. Fierce rejection by religious institutions often took expression in appalling forms of abuse, much of this linked to their religious objections to homosexuality. A male sex worker, aged 26 and from Mombasa recalled:
“Religious leaders have neglected me and do not want to be associated with me. This has left me very lonely. They always point fingers at me. The pastor even made me stand before the congregation and after telling them that I was a sex worker, he excommunicated me from the congregation. I will never forget how all those people shouted at me, calling me all sorts of names. I was really traumatized by this incident, to the extent that I tried to commit suicide.”
Agency, survival and resistance
Although the study did not set out to capture the long-term psychological consequences of experiencing such high levels of recurrent abuse, public humiliation and the ever-present risk of violence, this theme emerged quite strongly in our participants’ narratives. After reeling off a list of violations she had experienced in her work, for example, one Ugandan woman could go no further, describing these memories as “very heavy”.
To cope with the challenges of working under extreme stress and living with the deep levels of trauma that result, many sex workers described developing what can only be termed ‘survival strategies’. Some attempted to be discerning in their selection of clients, hoping that by scrutinising them carefully, they would choose only non-violent ones:
“…some people look strange, so I don’t pick those who look strange.” (35 year old female, Bulawayo)
This strategy, of course, only worked some of the time, and many could not afford financially to be selective with clients. Others developed ways to trick, avoid or even confront the police. For example, when military police in Uganda rounded up a group of sex workers and raped them,
“…the only one who survived played a trick and started vomiting, saying that she was very sick and no military officer could rape a person who was vomiting.” (32 year old female, Kampala)
In some cases, sex workers literally fought back against their abusers and succeeded in overpowering them. A focus group participant in Bulawayo recalled her response when assaulted by a police officer:
“Unfortunately one of the policemen who had arrested me got angry because I refused to bribe them. He took me to another room and started slapping me. Later he took his stick and started beating me up. I don’t know what got into me that moment but I shot up at him and beat him nearly to death. When I came back to my senses his arm was broken, he no longer had his shirt on and the room was upside down. I still can’t believe they let me go after that.”
Such acts of direct resistance – particularly those that enabled sex workers to escape further violence – seemed rare, however. To avoid arrest or to escape dangerous situations, sex workers commonly gave in to police officers’ demands for bribes, whether involving money or sex. Importantly, sex workers characterised these actions of the police as “theft” or “robbery” rather than bribery, a strategic reframing that may in itself serve as an act of resistance.
As described above, reporting incidents to the police was seldom considered a viable option. But not all sex workers who had been violated accepted that they had no recourse to the law. A woman from Thohoyandou, Limpopo, showed that standing up for one’s rights could have a positive outcome. After agreeing on a rate and spending the night with a client, he refused to pay.
“Then I told him that, ‘I will get you arrested.’ I took his car keys and went to the police, I told the police that I had an agreement with someone who promised to give me R500 [about 33 pounds] but he did not. So the police said I must wait until he comes to the police station. Within 20 minutes he arrived, then he told the police we agreed on R200 and now I want more. Then the police asked me if he used a condom and I said no. Then the police said he must give me my money in full and I must give him the car keys.” (21 year old female, Thohoyandou)
Occasionally, sex workers used innovative approaches to confront their would-be abusers, by actively taking control of the situation and demanding respect. This same participant explained:
“On the 31
st
of December l called some of my clients for a party at my house and I explained to them the bad things that they do to me and give me stress. Some are now more than my clients; they are now like my friends or cousins. One day I met one of them at the shopping centre then he just greeted me and gave me R20 [about 1.30 pounds] to buy drinks.” (21 year old female, Thohoyandou)
One of the few respondents who reported having had no experiences of police harassment or abuse was a male sex worker aged 24 from Zimbabwe whose clients were women, a factor that for him explained why he was, effectively, ‘invisible’ to the police.
“With matters regarding sex work I have not had any problems with the police. The reason for this is probably that I’m not gay and the police don’t know much about male sex workers who are straight. So whenever I bump into a police officer while looking for clients, they don’t even give me problems because they would be thinking that I am doing other kinds of business, not sex work. It’s really a good thing that the police are ignorant about this kind of job.”
This decision to remain underground and operate covertly as a sex worker was not mentioned by other participants, but may well be a strategy to avoid police targeting that is used more widely in the study sites by sex workers who were invisible even to our interviewers.
Building resilience through collective action
In addition to individual coping strategies, many participants mentioned the importance of collective action, for example, in building friendships and solidarity with fellow sex workers. Several highlighted the need for unity among sex workers:
“If we are united, we can do whatever is possible to ensure that people don’t despise us.” (28 year old female, Kampala)
Participants also discussed the notion of being proactive and participating more fully and more visibly in broader community work, implicitly rejecting deliberate efforts to exclude them. Mobilising sex workers to initiate their own projects was also felt important,
“…because nobody will come from outside to help sex workers. We as sex workers should lobby for our own health facility which is well equipped and furnished with drugs. This will improve our health and welfare, such that people look at us as people who are well off. Together we can.” (Female focus group, Kampala)
Some sex workers in Uganda reported having started up savings groups and other microfinance schemes among themselves. While essentially a positive initiative, as it had encouraged disciplined saving among sex workers, there were challenges in the timely payment of contributions and, in some instances, in
“…the treasurer eating the money and promising to pay when her client comes.” (Female focus group, Kampala).
Aside from the financial and potentially political importance of initiatives to bring sex workers together, these were also described as important for psychological reasons:
“When we sex workers meet together, we discuss many issues and advise one another. We comfort ourselves and come with good ideas, which can help us and this makes us feel like we are also human beings and relieves us from stress.” (Female focus group, Kampala)
The high mobility of sex workers, however, may hamper their efforts to form sustainable groups or collectives. Several participants pointed out that while they would like such groups to form in their areas, the transient nature of sex workers lives would likely undermine the continuity and longevity of such groups. Additional challenges were posed by the threat – or reality – of police harassment:
“It is difficult for us to have groups in my place because when police find out that there is a group of sex workers they can beat us and arrest us.” (Female focus group, Kampala)
Participants emphasised the importance of support from local NGOs dedicated to supporting sex workers, where these existed. This support could take many forms, from working together in advocacy, facilitating sex workers to form their own groups, improving legal redress, supplying bail for arrested sex workers, to offering training in human rights defence and practical skills building. A woman in Bulawayo and another in Hillbrow explained how sex worker NGOs help them to assert their rights:
“We are being assisted by the Sexual Rights Centre, they hold workshops for us and it is through them that I have come to know my rights.” (42 year old female, Bulawayo)
“[When experiencing abuse] I call the Sisonke member to ask them what I am supposed to do, because some of us, we don’t know our rights.” (34 year old female, Hillbrow)
Collective empowerment of the sex worker community through building knowledge of their rights cannot be overestimated. When sex workers have been trained and supported in this way, it can foster the confidence and resilience of individual sex workers to take control of dangerous situations. Revealing a potentially useful strategy, a sex worker from Hillbrow claimed that he confronts the police and states his rights, which usually results in them leaving him alone: “Most of the cops, they always say I am crazy, because I always tell them about my rights.” (25 year old male, Hillbrow).
In addition to establishing sex worker groups and support organisations, participants identified other potentially empowering interventions. These included training to improve their sex work skills (as one woman in a focus group in Kampala put it, to enable them to “do our work well”); English language classes, adult literacy training and broader skills training for sex workers themselves, “because most sex workers, we did not get good education” (Female, 28 years, Mombasa). They also appealed for religious institutions to learn more about the context of sex workers’ lives and thus re-evaluate their attitudes towards sex workers, and for training of police and health workers to make them aware of the trauma caused by their actions. Similarly, others called for support to
“…get connected with the local leaders and the police so that the give us peace and they stop harassing us.” (Female focus group, Kampala)
Finally, they made a strong request for “a better place” and “a building” (female focus group, Musina) where street-based sex workers could live and work in safety.
Discussion
Sex workers in the four African countries face diverse forms of violence from all sections of society with whom they interact, from clients, police, landlords and brothel owners, to family and community members. Acting in concert, such forces help to legitimize inequality, alienation, and powerlessness, raising crucial questions concerning the human rights of sex workers in southern and eastern Africa, as elsewhere in the world. Though the socio-political context varies considerably in the four study countries, the experiences of sex workers were largely uniform across sites. Put another way, the experiences of sex workers as documented in this study reflect an alignment and interaction of state, law, social discourse, institutions, philosophies and general public opinions. Though varying somewhat in their exact expression between sites, these entities coalesce around the criminalisation, sexual moralism and associated stigmatisation of sex work. Such attitudes are fuelled by the rise in conservative, religious fundamentalism that is evident in many parts of Africa, and which condemns sex work - alongside homosexuality - and any rights-based discourse associated with them, as socially deviant. Similarly, clients’ treatment of sex workers as objects to be bought and “owned” may be a reflection of a broader gender conservatism in these societies, where women are regarded in general as property of men, with few rights to individual autonomy and freedom.
Consequently, individual sex workers are highly vulnerable to human rights violations, yet have very limited resources or possibilities to challenge perpetrators, or to seek justice and legal compensation. This in turn exacerbates their marginalisation and social exclusion, and limits the options available to them for rising above their precarious circumstances. Those already on the margins of society - such as cross-border migrants, refugees or men who have sex with men - are further isolated and stigmatised when they take up sex work, and enjoy even less protection from the law [
18‐
20].
Practically, the everyday circumstances described by sex workers impact profoundly upon their physical, mental and social wellbeing. Aside from the more direct forms of violence meted out by police or clients, and the humiliation caused by name-calling and “whore stigma” [
21], sex workers routinely experience more ‘indirect’ forms of violence. These take the form of deliberate exclusion from social gatherings and community initiatives, which for female sex workers often means remaining outside of the conventional bonds of solidarity among women, from which they might otherwise benefit. The even higher levels of humiliation and abuse extended to male and transgender sex workers culminate in a process of profound ‘othering’, where they are treated as objects decisively beyond the boundaries of decent society.
Both direct and indirect forms of violence impinge upon the space within which sex workers live and work, diminishing the control they have over this space and the way they can move and act within it. Violence, human rights violations and the ensuing trauma can thus be understood as ultimately stripping the person of a safe mental or physical space within which to retreat. This draws attention to the larger problematic of the interconnections of place, culture, and health [
22,
23] and the importance of understanding the marginalisation and violence so commonly experienced by individual sex workers in terms of the spatial dimensions of sex work more broadly [
24].
From a public health perspective, the criminalisation of sex work constrains efforts to reach the population with required health services, and ultimately, structural and legal reforms are necessary [
25]. These should align public health and human rights goals, and promote protection of sex workers from violence, HIV and other social harms - goals that would be best achieved in a decriminalised legal framework [
26]. Only in South Africa has the possible decriminalisation of adult prostitution been raised in parliamentary discussions, triggering broad public debate, although actual law reform seems a long way off [
2].
The study has some limitations, stemming mostly from difficulties inherent in examining such a highly sensitive topic. Firstly, participants’ awareness of the risk of exposure to the authorities may have restricted the openness with which they shared information with the researchers. Indeed, some of the interviews were marked by troubling silences, with participants appearing to either conceal information or limit the degree of detail provided. Secondly, ‘snowball’ sampling tends to recruit sex workers that are more visible, cooperative, and interested in participating in research, rather than capturing a truly representative sample [
27]. Although efforts were made to select a heterogeneous sample that reflected the diversity of the sex worker population in each site, it is unclear whether this was actually achieved. It is also possible that the demographic composition of the interviewers (all black African females) influenced sample selection, leading to under-representation of male and transgender participants, and those of other races.
Thirdly, most interviewers had little or no previous research experience, since their background was essentially that of peer education and outreach work. The study budget allowed for only a three-day research methods training workshop, which perforce could only cover the key principles of research and research ethics. Comprehensive training in methods and interviewing skills was not possible. Thus, while there are distinct advantages to using peers to collect data (for example, trust may be established more easily than with non-peer interviewers, potentially yielding richer data), this approach poses considerable challenges. It also cannot be assumed that peers necessarily make good interviewers. By virtue of inhabiting the same local context as the participants, peer interviewers tend not to interrogate shared meanings as much as outsider researchers might. In this instance, interviewers more experienced at probing may have obtained more detailed information, thus enabling a more nuanced assessment of differences across sites and between sex work sub-groups. Peers may also have a vested interest in concealing certain information that could potentially reflect badly on their community or reveal hidden knowledge to outsiders. That participants are asked to share information and experiences with peer interviewers who may encounter them in their local context long after the research has ended, further raises the potential for confidentiality to be breached, or for participants to conceal information, fearing such breaches. By placing full responsibility for data collection and transcription in their hands, however, the peer interviewers in this project were able to learn valuable research skills, broaden their understanding of the experiences of sex workers in their area, and develop links for future advocacy and capacity-building possibilities.