A qualitative study identifies barriers and facilitators affecting female sex workers' access to sexual health services in Arak, Iran.
The sexual health of female sex workers is of considerable concern, particularly due to significant complications arising from multiple unprotected sexual relationships. A groundbreaking qualitative study conducted for the first time in Iran has delved deep to explore the intricacies behind the barriers and facilitators to accessing sexual health services among women at high risk of sexually transmitted infections (STIs) residing in Arak.
The study, involving fourteen female sex workers who visited the specialized HIV center within the city, was executed through semi-structured interviews. Researchers utilized content analysis to comprehend the needs, barriers, and the helping hands available to these women, substantially fueling discourse on sexual health within such marginalized communities.
Importantly, three overarching themes emerged from the data gathered: barriers and facilitators concerning the access to sexual health services, the pressing educational needs around sexual health, and the role of peer education. Various barriers were categorized under three main headings: personal, environmental and structural, psychological and social barriers.
Personal barriers were often related to issues like lack of information, privacy concerns, fear of untreatable diagnoses, and prevalent cultural beliefs associated with shame. For example, one participant shared, “Many feel scared to go to the doctor because they worry if the doctor suddenly says it’s a serious illness and can’t be treated, then they’ll become helpless and won’t be able to live anymore.”
Environmental and structural barriers included financial restrictions, inadequate focusing on sexual health within healthcare systems, experiences of harsh treatment by healthcare staff, inadequate quality of distributed condoms, or lack of preventive education. A poignant remark by another participant illustrated this: “Now, even if someone gets examined, where would they get the money? For example, they say if we do a Pap smear, we should pay at least 200,000 tomans.”
On the other hand, facilitators to access included respectful treatment, effective counseling, availability of screenings and vaccinations, and the distribution of condoms at the HIV center. One participant noted the significance of free health services by expressing, “The free screenings and vaccinations make me feel safe and protected. Knowing I can get checked and vaccinated without worrying about the cost gives me peace of mind and helps me take care of my health.”
The educational needs outlined by the participants encompassed domains such as negotiation and communication skills, along with preventing and managing STIs. Many mentioned difficulties asserting their health needs and shared, “If I want to have a relationship with my sexual partner, I can’t say ‘must’ or ‘never.’ I just ask if he can do it, but I can’t command him to do something like I can’t tell him he must use a condom.”
The findings also underscored the necessity for effective peer education, recognizing both its strengths and weaknesses. Participants echoed the limitations of peer education on certain occasions, indicating, “Health centers don’t open up about sexual issues and don’t examine them or provide awareness to their clients... centers need gynecologists and psychiatrists.”
Overall, the study emphasizes the urgent need for cultural change, enhanced training for healthcare providers, and improved infrastructural support to empower female sex workers. Suggestions for the way forward include actionable strategies to reduce stigma and create comprehensive, respectful access to sexual health services. Emphasizing the enhancement of sexual health education on multiple fronts can expect to yield future benefits for this vulnerable population.