Social Science & Medicine 369 (2025) 117785

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Food insecurity, intimate partner violence, and barriers to sexual and

reproductive health care among women in Lorentzville, South Africa
Lucy Khofi a,b,* , Lenore Manderson a,c , Eileen Moyer b
a
School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
b
Department of Anthropology, University of Amsterdam, Amsterdam, the Netherlands
c
School of Social Sciences, Monash University, Melbourne, Australia

A R T I C L E I N F O A B S T R A C T

Handling editor: Alexandra Brewis Aims: In this article, we explored the ways that food insecurity, gender, migration, and intimate partner violence
(IPV) intersect with and restrict access to sexual and reproductive health (SRH) services among women engaging
Keywords: in sex work in South Africa.
Food insecurity Methods: We draw on broader qualitative data collected between 2022 and 2023 through ethnographic methods.
Gender-based violence
This article specifically draws on data from in-depth semi-structured interviews with 15 participants. Thematic
Migration
analysis was employed to examine the socio-economic and structural conditions shaping women’s lived expe­
Sexual and reproductive health
Transactional sex riences, focusing on their adaptive strategies to mitigate food insecurity and access SRH services.
Results: We argue that food insecurity drives transactional relationships, with hunger influencing economic
choices while contributing to women’s vulnerability to gender-based violence and limiting their access to SRH
services. This limited access, especially to contraception and abortion, further exacerbates the risks faced by
these women, exposing them to compounded health and social challenges. We show that impoverished inner-city
women experience significant gaps in healthcare and social welfare systems. We emphasize the need to view
women’s actions as adaptive strategies to constrained circumstances.
Conclusion: We underscore the need for comprehensive policy interventions that expand healthcare access for
migrant populations and address the economic vulnerabilities that propel women into transactional sex. Our
findings contribute to the literature on gender, migration, and survival strategies, demonstrating the importance
of intersectional approaches in addressing food insecurity, violence, and reproductive justice.

1. Introduction Economic insecurity, legal exclusion, and gender inequality intersect to

result in a form of structural violence (Musariri, 2021), pushing some
Structural violence places women in precarious living situations women into transactional sex. In inner-city Johannesburg, particularly
where their reproductive autonomy is compromised. Drawing on women without legal documentation or formal work permits face sig­
ethnographic research conducted in the suburb of Johannesburg, Lor­ nificant barriers to securing stable employment, impacting their ca­
entzville, South Africa, we analyse how systemic factors such as exclu­ pacity to meet everyday expenses, including housing and food costs.
sion from formal employment and healthcare leave women dependent In this article, we draw on data from a doctoral study that took as a
on transactional sex to meet both economic and reproductive needs starting point the WEF (water, energy, and food) Nexus, from which
(Ware et al., 2021; Fedina et al., 2022; Jewkes et al., 2023). Limited point to consider how water, energy, and food-related insecurities
access to sexual and reproductive health (SRH) services among these intersect with wider societal concerns such as gender-based violence and
women reflects and results in entrenched cycles of abuse and poverty sexual and reproductive health. The research was conducted in Lor­
(Lundqvist, 2023). entzville (see acknowledgments), on the edge of the central business
Structural violence, as termed by Johan Galtung (1969), refers to the district of Johannesburg, to consider how unemployed women navigate
way systemic social structures harm or disadvantage individuals by these challenges. Our qualitative research shows the need to attend to
restricting access to resources or opportunities (see also Farmer, 2004). how these resources are interconnected across grassroots, individual,

* Corresponding author. School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
E-mail addresses: [Link]@[Link], lucykhofi.n@[Link] (L. Khofi).

[Link]
Received 11 July 2024; Received in revised form 22 January 2025; Accepted 27 January 2025
Available online 31 January 2025
0277-9536/© 2025 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license ([Link]
L. Khofi et al. Social Science & Medicine 369 (2025) 117785

household, and national levels (Khofi et al., 2024). Many resort to gender-based violence (GBV) and intimate partner violence (IPV).
various forms of sex work or transactional exchanges as a survival Below, we use the term IPV to refer specifically to violence within
strategy. None reported doing so as a choice; rather, they viewed intimate relationships, while GBV captures a broader spectrum of abuse
transactional sex as a temporary response to immediate needs shaped by physical, emotional, and sexual often beyond intimate partnerships. The
the limited options available to them. two terms reflect that women in this study experienced violence both
from intimate partners and from clients, family members, acquain­
1.1. Background tances, and strangers; they encountered varied forms of abuse across
intimate, social, and economic relationships.
Through a focus on migrant women in Lorentzville, we explored the Studies from southern Africa highlight that many women, particu­
intersections of migration, legal status, and healthcare access by women larly undocumented migrant women resident in urban informal settle­
who frequently rely on transactional sex as a means of survival. This ments, engage in transactional sex as a strategy to cope with poverty and
dependency increases their exposure to risks such as unintended preg­ hunger without self-identifying as sex workers (Stoebenau et al., 2016,
nancies, exploitation, and violence. The convergence of gender, migra­ 2023). As suggested above, these women engage in transactional ex­
tion, and economic precarity creates unique challenges for changes situationally and sporadically in response to economic need, so
undocumented women, who, unlike citizens, are doubly marginalised. underscoring the role of sex work as a coping mechanism. Women
Migration and legal status are important factors influencing access to oscillate between different forms of economic exchange, sometimes
employment, income, and health care and protecting or exposing engaging with clients in brothels and, at other times, providing trans­
women to violence in South Africa (Landau, 2011; Vearey, 2018). actional sex in various settings to meet basic needs like food and shelter.
Although South African citizens experience barriers to sexual and Labeling these women as "sex workers" oversimplifies their survival
reproductive health services and may also be reluctant to report strategies and ignores the structural pressures to which they are subject
gender-based violence (GBV) (Msipa and Masango, 2024), these barriers (Stoebenau et al., 2011).
are greater for women born in South Africa but who lack identity papers. Economic precarity and food insecurity significantly increase the risk
These barriers are greater still for foreign-born women, with xenophobia of gender-based violence (GBV) (Agrawal et al., 2023). As indicated
exacerbating the challenges they face (Dodson and Crush, 2004). above (and see Stoebenau et al., 2016; 2023), women’s engagement in
Irregular legal status, stigma, discrimination, and fear of deportation or transactional or informal sex is often a direct response to economic
further marginalisation, heighten women’s exposure to exploitation and precarity, creating a cycle of vulnerability, dependency, and violence
limit their access to sexual, reproductive, and healthcare (Msipa and (Petersen and Mkhize, 2023; Hatcher et al., 2022). While researchers
Masango, 2024; Musuka et al., 2024; Mukutiri, 2023; Obisie-Nmehielle have explored the links between poverty, food insecurity, and IPV, little
et al., 2023). Even migrant women with legal documentation may attention has been given to how food insecurity influences women’s
struggle to secure suitable employment, as foreign qualifications are engagement in transactional sex (Stoebenau et al., 2023). We address
often unrecognised, limiting them to lower-paying, precarious work. this gap by examining how hunger compels women to seek income
Migrant women engaging in transactional sex face additional risks through sex-for-survival practices, which in turn increases their expo­
when interacting with public services as well as when negotiating with sure to violence. We emphasize that economic precarity both exacer­
clients, deepening their dependency on informal networks and bates physical vulnerabilities and limits reproductive autonomy, as
increasing exposure to violence. In the following, we write of trans­ women become reliant on abusive partners or clients for survival.
actional sex to encompass a broad range of sexual exchanges than sug­ In South Africa, despite the legalization of abortion, access to ser­
gested by sex work (Stoebenau et al., 2016), whereby sexual exchanges vices is severely constrained by structural and social barriers (Rucell
may be regular or a secondary or temporary measure to address im­ et al., 2024; Macleod et al., 2022). This includes a shortage of trained
mediate financial needs for food, goods, or other non-monetary benefits. healthcare providers, with many exercising conscientious objection
This frequently emerges in contexts of economic hardship, as people based on moral or religious grounds, refusing to perform abortions. This
utilise their bodies to secure essential resources; in this context, the lines is particularly the case in rural areas, where healthcare services are
between sex work and survival strategies are blurred (Stoebenau et al., already limited, exacerbating existing inequalities (Du Plessis and
2023). This category illustrates a flexible coping mechanism that en­ Macleod, 2024). Public healthcare facilities face significant resource
ables people to navigate their circumstances without fully identifying as shortages, including inadequate staff and equipment, hindering their
sex workers (Stoebenau et al., 2016). These distinctions illuminate the ability to meet the demand for services. Furthermore, stigma and
interconnection between economic necessity and personal agency in mistreatment from healthcare workers deter women from seeking care,
addressing poverty, with individuals adopting varied approaches in while widespread misinformation about the legality of abortion further
response to resource scarcity. Many women in this study did not obstructs access to essential services (Macleod et al., 2022). Again, these
self-identify as sex workers but engaged in sex-for-survival practices to barriers are especially acute for undocumented migrants and margin­
meet basic needs, supporting arguments that sex work should be un­ alised women.
derstood as part of a spectrum of coping strategies (Masondo, 2024; This paper contributes to the understanding of how structural
McMillan et al., 2018). violence, combined with food insecurity, economic hardship, and
We build on this body of literature by focusing on the intersections of gender-based violence, affects the reproductive autonomy of migrant
reproductive health, economic precarity, and violence within trans­ women in urban South Africa. By highlighting the complex experiences
actional relationships. As we describe, the women interviewed of women engaging in transactional sex as a survival strategy, it chal­
emphasised that their primary reproductive health concerns were access lenges the simple view of sex work and emphasises the many factors that
to contraception and abortion services, as they did not want more shape survival when access to both formal employment and healthcare
children. Some participants who were in romantic relationships is limited. This research builds on existing literature linking economic
expressed anxieties about unintended pregnancies, explaining that oc­ hardship with increased vulnerability to violence, offering insights into
casional transactional sex raised uncertainties about paternity and that the systemic barriers that prevent women from accessing reproductive
boyfriends or partners were not willing to contribute to raising children health services and support.
from such relationships.

1.2. Food insecurity and gender-based violence

Women who are involved in transactional sex are vulnerable to

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2. Methods many seeking food assistance for their families due to widespread
hunger. During one-on-one interviews, 15 women shared their experi­
2.1. Study setting ences of intimate partner violence and engagement in sex work as sur­
vival strategy insights that emerged organically and were not initially
Lorentzville, a densely populated area, exemplifies a unique socio- anticipated. The broader study in Lorentzville included 35 participants:
economic landscape marked by stark inequalities (Khofi et al., 2024). 23 females, 10 males, and two individuals of unspecified gender; the
The community consists largely of migrants from South Africa and other participants identified themselves in these gender categories. For this
African nations, including Zimbabwe, Botswana, Lesotho, Ghana, and article, we focus on 15 women who identified themselves as victims or
Somalia (Moyo, 2017). Many residents live in overcrowded, substand­ survivors of IPV. These participants shared their lived experiences of
ard housing, including makeshift structures made of corrugated iron, gendered violence, sexual and reproductive health (SRH) challenges,
cardboard, and plastic, or in repurposed buildings without formal title and transactional sex during in-depth interviews. To deepen our un­
deeds (Wilhelm-Solomon, 2022). Research indicates that nearly 80% of derstanding of these themes, follow-up semi-structured interviews were
residents lack the legal permits needed for employment, education, or conducted with all 15 women in alignment with the PhD data collection
residency, leaving them vulnerable to systemic barriers and unable to in 2022 and 2023. Among them, five identified as sex workers, four
meet basic needs (Moyo, 2017; Khofi et al., 2024; Manderson, 2024). reported occasional involvement in sex work, and six engaged in
This vulnerability is further compounded by poverty, unemployment, transactional sex (see Table 1).
drug use, crime, and widespread food insecurity. Unreliable access to The sampling process was grounded in purposive sampling, a method
water, electricity, and sanitation amplifies these challenges, leaving designed to select participants who could provide rich, contextually
streets littered with waste, a visible reminder of socioeconomic neglect relevant insights into the study’s aims (Palinkas et al., 2015). This
(Khofi et al., 2024). Despite South Africa’s status as a middle-income approach is well-suited for qualitative studies where participants’ lived
country, deep-seated inequalities rooted in its apartheid past continue experiences are central to understanding complex socio-cultural and
to create significant disparities in access to resources, healthcare, and gendered issues (Etikan et al., 2016). Strict ethical considerations guided
employment opportunities. the process, ensuring participant confidentiality and minimizing harm.
All participants were informed of their right to withdraw from the study
2.2. Research design at any point without consequences. Trust-building was a key element
facilitated by the first author active involvement in the partnering
In this article, we examined how food insecurity, gender, migration, community-based organisations and her advocacy background in
and intimate partner violence (IPV) intersect to restrict access to sexual women’s health. These efforts helped navigate sensitive power and
and reproductive health (SRH) services for women engaged in sex work gender dynamics within the community. It is noteworthy that while the
in South Africa. Using an ethnographic approach, we provide a holistic 15 participants shared Gendered violence and related challenges
understanding of their lived experiences within socio-cultural and eco­ voluntarily, others did not report any direct or indirect experiences of
nomic contexts. While the localised focus limits generalisability, this abuse. Probing for further details was limited to those who willingly
method captures the complexity of systemic and personal challenges, shared their experiences, ensuring that participation remained volun­
offering rich qualitative insights into an under-researched area. tary and respectful of personal boundaries.
Conducted between 2022 and 2023 as part of a broader PhD study,
the research utilised ethnographic methods to explore the socio- 2.4. Data collection, quality, and validation
economic and gendered dimensions of the water-energy-food nexus,
focusing on lived experiences in urban settings. Data collection included For this paper, data collection was conducted through in-depth,
participant observation, informal discussions, focus groups, and in- semi-structured interviews between 2022 and 2023. Each interview
depth interviews. However, this paper draws exclusively on in-depth lasted 45–60 min and was conducted in English, the common language
interviews to examine women’s challenges related to SRH, IPV, and among participants. Interviews took place in participants’ homes,
access to services. The specific objective is to understand how women, ensuring a safe and comfortable space for discussing sensitive topics. All
particularly those involved in sex work or transactional sex, navigate interviews were audio-recorded with participant consent, and field
these challenges within the socio-economic context of Lorentzville. notes were taken to document observations and reflections. A total of 15
interviews were conducted, including follow-up interviews with par­
2.3. Sampling and recruitment ticipants to explore emerging themes further.
The interview questions focused on three key areas: access to sexual
Participants were purposively selected from two partnering and reproductive health (SRH) services, intimate partner violence (IPV),
community-based organisations involved in the broader PhD study: The and strategies for navigating socio-economic challenges. The first au­
People’s Pantry (TPP) and Love Our City Klean (LOCK). TPP operates thor’s regular engagement with the community, particularly through
community kitchens where meals are served to community members participation in food distribution initiatives at TPP and LOCK, helped
once a week, addressing immediate hunger. In addition to this, TPP runs establish trust and rapport with participants. Logistical challenges, such
a warehouse where, later in the week, community members can redeem as high crime rates, necessitated the presence of a community volunteer
points earned through LOCK’s recycling program. LOCK is an initiative from TPP during interviews to ensure the safety of the author. Whenever
promoting environmental sustainability by encouraging community the first author conducted one-on-one interviews with participants in
members to recycle materials such as paper, plastic, bottles, old appli­ their homes, the volunteer waited outside the participant’s home to
ances, and electrical cables. The points earned from recycling are maintain privacy and confidentiality during the interview.
exchanged for food parcels at TPP’s warehouse. To support its food Data quality was maintained through regular discussions with the
distribution programs, TPP relies on repurposed food items donated by research team, and external validation was provided by peer re­
Food Harvest SA, an initiative that rescues surplus food from retailers, searchers. The interview transcripts and field notes were imported into a
farms, and manufacturers to combat food waste and hunger simulta­ Word document for thematic coding using a combined inductive and
neously (Khofi et al., 2024). LOCK, in partnership with TPP and com­ deductive approach. Deductive themes were informed by existing
munity leaders, hosts workshops on maintaining clean streets and literature and the research objectives, with a focus on hunger, food
protecting the local environment, creating additional opportunities for insecurity, and access to water and energy. These pre-existing themes
community engagement. guided the initial stages of coding (Braun and Clarke, 2006).
Study participants were primarily drawn from these initiatives, with To ensure the validity and reliability of the findings, data validation

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Table 1
Participants demographics.
Name Age Years in any form of sex Type of sex work Number of Partner Nationality Legal Status in SA How Long Living in
work Children -undocumented SA

Najma 35 10 Self-identified sex 3 YES Nigeria Migrant 7 years

worker
Lynda 28 5 Occasional sex work 2 YES Cameroon Migrant 15 years
Zoe 32 8 Transactional sex work 1 NO Zimbabwe Migrant 4 years
Zelda 29 6 Occasional sex work 0 NO Zambia Migrant 2 years
Hanna 25 3 Occasional sex work 1 NO Kenya Migrant 6 years
Christina 31 7 Transactional sex 2 YES Zambia Migrant 3 years
Zozo 33 9 Self-identified sex 4 YES SA – Free State Citizen Native South African
worker
Nono 27 4 Transactional sex work 0 YES SA – Gauteng Citizen Native South African
Lihle 30 6 Transactional sex work 3 YES SA – Kwa-Zulu Citizen Native South African
Natal
Molly 26 5 Occasional sex work 2 YES Zimbabwe Migrant 12 years
Ludick 34 8 Self-identified sex 1 YES Nigeria Migrant 9 years
worker
Nadia 29 7 Self-identified self- 2 YES Cameroon Migrant 11 years
worker
Zethu 20 1 Transactional sex work 0 YES SA – Kwa-Zulu Citizen Native South African
Natal
Carthy 23 5 Self-identified sex 1 YES Namibia Migrant 20 years
worker
Nelly 21 3 Transactional sex work 1 YES SA – Free State Citizen Native South African

was an ongoing process within the broader study framework, involving 3. Results
co-authors at every stage. Emerging themes were regularly discussed in
team meetings, where further probing and refinement were identified to 3.1. FSWs narratives in Lorentzville
deepen understanding.
As the analysis progressed, additional themes emerged organically In Lorentzville, the intersection of intimate partner violence (IPV)
from the data, such as issues related to SRH services and IPV. While and pervasive poverty exacerbates the severe deprivation of basic re­
these themes were not explicitly predefined in the interview protocol, sources among women engaged in the informal economy, including sex
they naturally emerged through open-ended questions designed to elicit work. Participants reported extreme poverty, resulting in critical
participant experiences within the broader context of resource insecu­ shortages of essential resources such as food, water, energy, and shelter.
rity. In this case, “organically” refers to themes that arose from the Many reported enduring days without food as they struggled to provide
participants’ own narratives rather than being predetermined in the for themselves and their families.
research framework. Many women found themselves residing in neglected buildings or
Thematic coding was carried out through iterative discussions apartheid-era houses, lacking proper documentation or title deeds,
among the authors, ensuring alignment and reflexivity. After each which effectively denied them access to municipal services, including
interview, the first author engaged in reflective practices, including electricity and clean running water (Khofi et al., 2024). The constant
listening to audio recordings, transcribing them, and preparing the threat and experiences of IPV further constrained their ability to access
material for coding. This process allowed for a comprehensive explo­ basic necessities. Khofi and colleagues (2024), writing on expressions of
ration of the complex issues raised by participants and facilitated hunger in Lorentzville, highlight the socio-economic precarities that
continuous refinement of themes as new insights emerged. extend beyond mere hunger, with participants referring to various forms
First author took detailed field notes during the data collection of deprivation when discussing their experiences of being hungry.
process. These notes were used to reflect on the data and share insights Abusive partners often controlled financial resources and restricted their
with co-authors, ensuring a shared understanding of the themes. The movements, exacerbating their vulnerability and marginalisation.
chapters relevant to this study were circulated within the research team The majority of participants were foreign nationals without legal
and with external research groups for discussion, peer feedback, and documentation. The ages of participants varied, reflecting diverse ex­
validation. This collaborative process helped refine interpretations and periences and backgrounds. Some women began engaging in the
ensure the rigor and depth of the analysis. informal economy, including sex work, in their late teens and early
twenties due to dire economic circumstances. This illustrates how socio-
2.5. Ethical considerations economic pressures shape the decisions of women at different life stages.
The distinctions in legal status among migrants (Table 1) are particularly
Ethical approval for this study was granted by the University of the relevant, as this affects access to services and opportunities. Migrants
Witwatersrand Human Research Ethics Committee (Medical), with with work permits may have access to formal employment and social
Ethics Number M220760, ensuring compliance with ethical standards services, while those without legal documentation are often relegated to
for research involving vulnerable populations. Informed consent was the informal economy. The term "partner" refers to individuals with
obtained from all participants, who were made fully aware of the study’s whom the participants have intimate relationships, which can include
objectives, methods, and their right to withdraw at any point without varying degrees of emotional support and financial control. Under­
penalty. To safeguard confidentiality, pseudonyms were used in all standing the dynamics of these relationships is crucial, as they signifi­
reporting. Interviews were audio-recorded with participants’ consent, cantly impact the women’s economic choices and their ability to
and all data were securely stored in accordance with ethical guidelines. navigate the challenges posed by IPV and poverty.
For participants who shared their experiences of intimate partner
violence (IPV), appropriate referrals to local Gender-Based Violence 3.2. Setting the scene in Lorentzville
(GBV) centers for counseling and support were provided, along with toll-
free helpline numbers for additional assistance. Women gather along the edges of a street beneath a bridge in

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Lorentzville, an ordinary setting for an ongoing routine that blends into participants expressed challenges accessing reproductive health ser­
the city’s landscape. Some women stand alone, others are in pairs or vices, including both abortion and contraceptives.
small groups, observing the surroundings or chatting amongst them­ Despite the legality of abortion, participants reported numerous
selves. Cars approach slowly, some pausing beside a woman to exchange obstacles. Clinics sometimes outright refused to provide these services,
a few words through the open passenger-side window. A range of ve­ while others lacked sufficient capacity, leaving the women vulnerable.
hicles arrives in intervals, from luxury models like BMWs and Land Zelda explained that “some public clinics and hospitals turned us away
Rovers to older, well-worn cars. In quiet exchanges, some women enter because there was only one abortion provider, which means a lack of
the cars; others wait for the next interaction. capacity. It’s frustrating because abortion is legal, but accessing it is still
During fieldwork, first author encountered some of these women in a challenge." Ludic said, "It is hard to access abortion services freely in
connection to research conducted at The People’s Pantry (TPP), a small clinics. Even when you see a sign for ’Termination of Pregnancy’ and
non-government organisation providing food parcels and running soup enter the ward, you’re told either that the designated provider has
kitchens. As women gathered to receive food or share a meal, conver­ resigned or that they aren’t available, and you must come back in a few
sations offered glimpses into their everyday lives beyond the street weeks. But if I come back more than 12 weeks pregnant, it becomes even
scene. Many women spoke openly about the challenges they faced, more difficult to get their help. I was once told they didn’t have a nurse
sharing how transactional relationships have become part of a survival or doctor for surgical procedures, and they could only assist with med­
strategy to secure essential resources like food, clothing, and basic ne­ ical abortion if I were under 12 weeks. When I explained I had been here
cessities. Through interactions with these women, it became clear that weeks ago and there was no one to help me, they had no response … just
what was visible on the street was only one part of a much larger story of silence."
insecurity and survival, resilience and resourcefulness, shaped by eco­ This systemic failure is compounded by intimate partner violence, as
nomic pressures and the pursuit of stability. experienced by many self-identified sex workers whose partners exert
control over reproductive choices. Cathy’s experience highlights the
3.3. Obstructed access: reproductive health services in Lorentzville financial barriers to obtaining abortions in private care. She stated,
"Abortion was costly in private care. I was charged R1200 (approxi­
In South Africa, public clinics and hospitals are mandated to provide mately 63 USD), but I didn’t have the money. I ended up going to the
free contraceptive options, including oral contraceptives, injectables, clinic but faced rejection again."
implants, condoms, and emergency contraceptives, along with coun­ Undocumented migrant women faced additional barriers when
seling to support informed choices. Additionally, the Choice on Termi­ seeking abortion services. Nadia expressed, "I am scared to go to a public
nation of Pregnancy Act legally ensures access to abortion services up to clinic because I don’t have papers. I’ve heard stories of women being
12 weeks of pregnancy in public facilities, with extended access up to 20 reported and deported." This fear intensifies their vulnerability. Some
weeks under certain conditions (Rucell et al., 2024). This framework is participants turned to illegal abortion providers, with some placing their
intended to make safe reproductive health services accessible to all lives in jeopardy as a result. Zelda called a number from a billboard
women. advertising "quick abortions." Upon arrival, she found the location was a
In practice, however, the one public clinic located in Lorentzville flat in the CBD with no clinical facilities or medical tools, but many
struggles to meet these requirements. Nearby facilities such as those women were coming and going. One young woman leaving was visibly
found in the adjacent suburbs of Hillbrow, Yeoville, and Jeppe in pain, moving slowly and bleeding, with a large bloodstain on her
frequently experience shortages of basic contraceptives like injectables pants. Zelda asked if she was okay and ended up walking her back to her
and pills, leaving gaps in service that force women to rely on irregular flat. The young woman recounted that during the procedure, something
supplies or turn to private alternatives. Abortion services are also often was inserted, and the fetus was pulled out without any painkillers or
unavailable; staffing issues and high turnover rates limit access, with proper care. Zelda said this experience left her terrified of illegal abor­
some clinics lacking trained providers altogether. Zoe’s experience tions. The intertwining of IPV and systemic barriers to contraceptive
illustrated this challenge when she learned that Hillbrow Clinic was no access presents a critical challenge for self-identified sex workers.
longer offering abortion services due to a lack of trained staff, leaving
her without options. While alternative services like Women on the Web 3.5. Intimate Partner violence and women who sell sex
(Crossett et al., 2023) offer online prescriptions to enable medical
termination, many women have limited internet access and lack digital Barriers to contraceptives and abortion are further complicated by
literacy. Consistent and accessible reproductive health services remain intimate partner violence, where coercive control can limit a woman’s
out of reach for many. ability to make autonomous reproductive choices. This heightens her
vulnerability, exacerbates her marginalised status, and worsens if she
3.4. Obstructed access to contraception and abortion lacks documentation.
Women shared accounts of how their partners’ violence was often
Women’s access to contraceptives was often impeded by systemic tied to reproductive decisions. Partners resorted to violence, for
failures, including the unavailability of supplies at public health facil­ example, when women refused to terminate pregnancies or use con­
ities. Nelly lamented, "I went to the public hospital for contraceptives, traceptives. Zozo expressed, "My partner threatened to beat me if I didn’t
but they told me they were out of stock. It’s frustrating because these have an abortion … He said we couldn’t afford to feed more children, so
services are supposed to be free." This failure intersects with the expe­ I had no choice." Christiana explained that when she tested positive for
rience of IPV, where partners often demonstrate coercive control over pregnancy, it was difficult to tell her partner, as she occasionally
contraceptive use, further limiting self-identified FSWs’ autonomy in engaged in transactional sex with men she knew as neighbors: "I was
reproductive matters. worried whose child it is … I engage sexually with my neighbors, three
Women who self-identify as selling sex often face stigma within men who I know, and my partner knows them … (she took a long breath)
healthcare settings, whereby they are often denied essential reproduc­ … My worry was that when the child was born, he or she might look like
tive health services based on their occupation. Zelda stated, "I tried to the father, who I don’t know because I slept with all of them without a
get birth control pills once, but the clinic turned me away because they condom … including my partner." Her voice lowered. She added, "I was
said they couldn’t serve sex workers." Women who engage in trans­ terrified; I did not know what to do … Once I gathered the strength, I
actional or occasional sex work expressed similar challenges. Thandi told my partner, and he said, ‘Let’s have the baby removed … just like
shared, "Sometimes, I just do it once in a while to make ends meet. But that … he wanted the baby gone … he said he doesn’t want to raise
even then, when I try to access contraceptives, they treat me badly." All children that are not his."

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Conflict over condom use at times led to disagreements, which Lorentzville is a survival strategy driven by socio-economic hardships,
escalated into physical and sexual violence. Nono recounted, "When I primarily food and housing insecurity. This economic dependence re­
couldn’t get help at the public health clinic, my partner would beat me at stricts their reproductive autonomy and can, as indicated above,
home. He said I was irresponsible for getting pregnant and not taking heighten women’s vulnerability to intimate partner violence (IPV).
contraceptives." She continued: Limited access to reproductive healthcare, including contraceptives and
safe abortion services, exacerbates these challenges, further diminishing
When I don’t have contraceptives, I’m even scared to engage in in­
their ability to make empowered choices. The study points to a need for
tercourse with my partner because he tricks me. Countless times, he
policies that address both structural barriers and healthcare inequities
pinched the condom in front and pretended like it was broken, then
that compromise women’s safety and well-being.
he would force himself on me and force us to continue. He doesn’t
Women involved in transactional sex, self-identified sex work, or
have sex with a condom … he says it distracts him, that he doesn’t
occasional sex in South Africa navigate a survival strategy of sex work
enjoy it. But he also doesn’t want us to have children. So he blames
shaped by economic, social, and legal pressures. Economic necessity,
me if there are no contraceptives at the clinic and starts beating me
associated with high unemployment, poverty, and food insecurity, often
up, saying I’m responsible for making sure that we don’t make
leaves women with few alternatives for supporting themselves and their
children while he enjoys intercourse without a condom.
families. Such pressures push women toward transactional sex (Scorgie
Particularly for participants who already had children, a key concern et al., 2013; Jewkes et al., 2021). In Lorentzville, women rely on ex­
was to avoid having children. Many articulated a strong need for reliable changes for essentials like rent and food, particularly for their children,
contraceptive methods to prevent unwanted pregnancies, with some and often as a last resort. Similar findings from Botswana and Zimbabwe
stating that the lack of these options often left them vulnerable to reflect a broader regional trend, where socio-economic hardships drive
coercion from their partners. Molly, a mother of two, said, women to transactional sex as a coping mechanism (Dodson and Crush,
2004, 2021; Oliveira and Vearey, 2015).
One thing I make sure to avoid is having more children. I can barely
The intersection of race, class, gender, and civil status (i.e., not
afford the two children that I have now. Staying with my boyfriend,
having legal documentation) exacerbates the challenges faced by
who is also not working, when he gets home and there is no food, he
women, shaping their economic choices and interactions with social and
starts saying hurtful words … that I’m useless … that he can’t take
legal systems. Gendered violence from intimate partners and sexual
care of me … because I don’t hustle enough, like other women who
harassment from police officers is a reality for many women in trans­
sell their bodies. He’ll ask me … how much did I make that day … if
actional sex. The stigma surrounding sex work in South Africa and
there isn’t enough money, he starts beating me.
elsewhere in Sub-Saharan Africa often leaves these women trapped in
"It’s harder,” she added, “when he takes the money I worked hard for cycles of abuse. Law enforcement’s frequent harassment and violence
and goes to drink alcohol." Other participants too emphasised that they reveal a system that devalues marginalised women’s lives. Police bru­
did not want more children, hence their need for access to contracep­ tality against women in transactional sex has likewise been documented
tives and abortion. Some partners blamed women if they were unable to in Nigeria and Kenya (Richter and Vearey, 2016; Richter et al., 2014).
get contraceptives from the local clinic. Najma explained: Access to healthcare, particularly reproductive health services, is
another dimension of this systemic neglect. In South Africa, moralistic
They used to encourage us to use long-term contraceptives a few
views on transactional sex held by healthcare providers discourage
years ago, but now, the clinics and hospitals around here are always
women from accessing services, reinforcing the social stigma sur­
out of stock. Whether you want a pill or an injection, it’s usually not
rounding their work. Women often experience discrimination in clinics,
available … Our choice or preference doesn’t matter if you happen to
where assumptions about their sexual health lead to judgment or refusal
find any form of contraception; you just take it, even if your body
of services. This mirrors experiences in Namibia and Uganda, where
reacts badly to it … For instance, the injection doesn’t work for me; I
healthcare access for women in transactional sex is obstructed by social
prefer the pill or a hormonal implant.
prejudice (Jewkes et al., 2005; Richter et al., 2014; Dempsey et al.,
Undocumented migrants often engage in transactional or occasional 2024). These national and regional trends highlight how stigma within
sex work due to limited employment options. Maria, an undocumented healthcare settings perpetuates health disparities, particularly regarding
migrant, shared, "I never wanted to be a sex worker, but it was either contraception and abortion services (Jim et al., 2023).
that or watch my children starve. I have to do what I can to survive." For undocumented migrant women, the challenges are even greater.
Lynda added, "I never wanted to occasionally sleep with my neighbors South Africa’s immigration policies make even basic services out of
for favors, food, or to pay rent with my body … it is not my choice. I reach, as women fear deportation or harassment if they seek medical
ended up arranging with my landlord that I would pay him by sleeping help. In our study, some migrant women described how fear of detention
with him … this was not the easiest decision ever." Other participants and discrimination prevents them from accessing essential services.
also expressed that they were forced into this position by circumstances Similar barriers are faced by migrant women in Tanzania and
including unemployment: they didn’t have food at home and had to find Mozambique, where restrictive immigration policies and xenophobic
ways to meet basic needs. attitudes limit healthcare access, deepening their isolation (Dodson and
Other women who self-identified as sex workers described experi­ Crush, 2004; Lockett and Mash, 2024).
ences of police harassment and assault while waiting on the road for Reproductive health choices for these women are not only restricted
clients. Nelly recounted, "When I was standing there, the police officer by institutional barriers but also by relational dynamics. Many women
told me he was going to arrest me. He started pushing me, then slapped face pressure from male partners who oppose contraception or abortion
me with his hand and said I would have to sleep with him if I didn’t want or alternatively insist on them, compromising women’s reproductive
to be arrested." Similarly, Najma shared that when she went to the police autonomy. This imbalance of power forces women into a double bind
station to report an IPV assault by her partner, the officer demanded a where their reproductive choices are constrained by both societal ex­
sexual favor in exchange for prioritising her case. Instead of being pro­ pectations and personal relationships. In Zambia and Malawi, women
tected by law enforcement, women often faced further assault and often also lack the support or autonomy needed to make independent
harassment from officers. reproductive decisions (Hunter, 2018; Silberschmidt, 2004; Zembe
et al., 2015).
4. Discussion Shortages in public health clinics further limit women’s access to
reproductive healthcare. Many participants in the study reported that
The findings of this study highlight that transactional sex in contraceptives like the pill, injectable contraceptives, and hormonal

6
L. Khofi et al. Social Science & Medicine 369 (2025) 117785

implants were often out of stock. Women have little choice but to accept women face, both from law enforcement and society. Advocacy groups
whatever contraceptive method is available, even if it is unsuitable for like SWEAT and Asijiki are advocating a sex work decriminalisation bill
their needs. Staffing shortages mean longer wait times and inconsistent in Parliament (Lakhani, 2022), but further action is needed. Research
services, making it difficult for women to obtain regular and reliable from countries where sex work is decriminalized shows that legal reform
care. Addressing these issues requires both destigmatisation, improved can improve women’s health and safety, enabling them to report abuse
availability of resources, and staff increases and support within public and seek protection without fear of legal repercussions (Armstrong,
health facilities. 2021; Richter et al., 2014; Richter and Vearey, 2016). The creation of
Food insecurity is a pervasive driver of vulnerability, with trans­ legal protections to address police misconduct and violence is also
actional sex often a survival strategy. Financial pressures are especially essential to rebuild trust in the justice system. Specific, actionable steps
acute for women with children, who bear not only the economic re­ to facilitate this decriminalisation process include.
sponsibility but also the emotional toll of this precarious existence.
Many participants described the painful reality of remaining in abusive • Engaging policymakers through regular advocacy meetings and
situations out of economic need, a sentiment echoed by women in other public forums to discuss the benefits of decriminalisation and reduce
Sub-Saharan African countries, where food insecurity limits women’s public stigma.
agency and keeps them in exploitative relationships (Gibbs et al., 2018; • Training law enforcement on human rights and non-discriminatory
Jewkes et al., 2023). practices toward sex workers to reduce violence and misconduct
There were notable silences in this research. Despite South Africa by police.
having one of the highest HIV prevalence rates globally, HIV was rarely • Establishing independent oversight bodies to monitor and address
mentioned as a concern among the women we interviewed in Lorentz­ police misconduct related to sex work.
ville. This omission could reflect a variety of factors, including gaps in
awareness, stigma surrounding HIV, or a lack of available resources In healthcare, inclusive policies are necessary to ensure safe, non-
tailored to the unique needs of women engaged in transactional sex. In discriminatory services for marginalised women, including migrants
other areas of South Africa, particularly urban centers like Johannesburg and others in vulnerable situations. Implementing sensitivity training
and Cape Town, sex workers and young women at risk of HIV exposure for healthcare providers, coupled with policies that guarantee migrant
have been targeted by HIV interventions. Programs funded by national women’s access to services, can reduce the stigma and discrimination
and international organisations provide access to HIV treatment and that currently discourage many women from seeking care. Ongoing
preventive measures, including Pre-exposure Prophylaxis (PrEP), which education for healthcare workers on how to effectively work with
has proven effective in reducing the risk of HIV infection among marginalised communities has been shown to improve attitudes and
vulnerable groups (Matthews et al., 2024; Shipp et al., 2024). Such service delivery (MacLeod et al., 2024; Dempsey et al., 2024). Imme­
services are largely absent in Lorentzville. Without targeted HIV pre­ diate and actionable steps include.
vention and treatment programs, women in transactional sex face
heightened risk, with limited avenues to safeguard their health. • Pilot programs for sensitivity training at local clinics and healthcare
In addition, we highlighted the intersection of intimate partner facilities, starting with high-risk areas or underserved communities.
violence (IPV), socio-economic disadvantage, and obstructed access to • Partnering with NGOs, community-based organisations, and local
reproductive health services, focusing on women engaging in sex work organisations to provide refresher courses for healthcare pro­
in Lorentzville. We uncovered how IPV, legal status, and poverty exac­ fessionals on serving marginalised communities, ensuring sensitivity
erbate barriers to essential health services such as contraceptives and and inclusivity.
abortion care. By documenting these challenges, we underscored the • Enacting clear policies to ensure migrant women’s guaranteed access
urgent need for policies that improve access to reproductive health to healthcare services, regardless of their legal or economic status.
services and address the systemic inequities faced by marginalised
women. Additionally, we offered valuable insights into the resilience of All clinics need to be well-stocked with a wide range of contraceptive
these women, demonstrating their agency in navigating complex socio- options, including pills, long-lasting injectables, and hormonal implants,
economic and health-related obstacles. This research contributes to the and should provide these services inclusively and without charge.
broader conversation on reproductive justice and gender-based Healthcare services should be tailored to meet the specific reproductive
violence, shedding light on the structural changes needed to support needs and preferences of women without imposing judgment or re­
marginalised groups. strictions. The integration of HIV prevention and treatment services into
However, this study is not without limitations. The focus on a spe­ these settings is also crucial. Given the high HIV prevalence in South
cific socio-economic context in Lorentzville limits the generalisability of Africa, including in communities like Lorentzville, expanding access to
the findings to other regions or populations with different socio-cultural Pre-Exposure Prophylaxis (PrEP) for women at risk and consistent
or economic circumstances. While the in-depth nature of the study treatment support for those living with HIV could substantially reduce
provided rich qualitative insights, the sample size and localised focus transmission rates. Specific actions to address these gaps include.
did not fully capture the diversity of experiences across broader urban or
rural settings in South Africa. Future research could build on these • Ensuring all clinics are equipped with a comprehensive range of
findings by exploring the intersection of food insecurity, IPV, and access contraceptive options and ensuring free access to these services for
to SRH services across different geographical regions and among various all women, particularly in low-income communities.
migrant groups. Additionally, the research could investigate the impact • Expanding the availability of PrEP in high-risk areas, especially in
of socio-economic factors, such as employment status and housing communities with high transactional sex activity, by integrating
conditions, on women’s health-seeking behaviours and the role of PrEP into primary healthcare services and ensuring it is readily
community-based interventions in addressing these issues. available at no cost.
• Strengthening HIV treatment adherence programs with community-
5. Policy recommendations and conclusion based outreach to ensure consistent care and support for women
living with HIV.
Addressing the challenges faced by women in transactional sex re­
quires a comprehensive approach that transcends criminalisation or Addressing food insecurity is essential to alleviate some of the eco­
stigmatisation. A critical first step is decriminalizing sex work in South nomic pressures that lead women into transactional sex. Policies aimed
Africa, which could significantly reduce the violence and harassment at ensuring social safety nets, including food pantries and housing

7
L. Khofi et al. Social Science & Medicine 369 (2025) 117785

support for women with children, can help reduce women’s vulnera­ (Netherlands).
bility to exploitation. Such structural support would provide women
with the stability needed to make choices that are not dictated by sur­ Data availability
vival pressures. Specific, actionable steps to alleviate food insecurity and
economic pressures include. Data will be made available on request.

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the patience and insights of the SSM Medical Anthropology Desk Asso­ income,+and+health+care+and+protecting+or+exposing+women+to+violence+
in+South+Africa&ots=pSshcUXSKQ&sig=ayMgP-97zyd3nI4iQNWPGPtZM5s&re
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