Discussion
This study shows that the sexual and reproductive health (SRH) of female sex workers (FSWs) is
shaped by many layers of influence, which can be understood through Bronfenbrenner’s Ecological
Systems Theory (1979). Instead of being the result of individual choices alone, the findings reveal
how everyday relationships, institutions, and broader social conditions all come together to affect
health outcomes.
At the microsystem level, the women’s closest interactions played a major role. Many participants
highlighted how peers were a lifeline—sharing information about contraception, offering support
during illness, and encouraging HIV testing. This peer solidarity echoes earlier research showing
that networks of sex workers can be a powerful protective factor (Kerrigan et al., 2015). On the
other hand, the same level also brought some of the harshest challenges. Encounters with clients
and even healthcare providers often involved stigma, rejection, or poor treatment. Several women
described being scolded or dismissed in clinics, a finding that matches Shannon et al.’s (2015) work
on healthcare discrimination as a barrier to care. This contrast—peers as a support system versus
providers as a source of exclusion—shows how the microsystem can both help and harm.
The mesosystem, where these immediate environments connect, was also critical. For instance,
when peer groups actively helped women access healthcare, the fear of stigma was reduced and
SRH services were more likely to be used. Where such connections were weak, women avoided
clinics altogether. Similar patterns have been observed elsewhere, where strong partnerships
between peer groups and institutions improved service uptake (Scorgie et al., 2012). This suggests
that building bridges between supportive networks and health systems can make a real difference.
Moving outward, the exosystem—the broader institutions and structures that indirectly influence
women’s lives—posed its own barriers. Limited NGO outreach, poor workplace protections, and the
absence of formal policy support left many participants without reliable access to care. These gaps
meant that women often relied on informal advice or short-term fixes, which increased their
vulnerability. This reflects wider research showing that restrictive environments and weak health
systems push sex workers into risky coping strategies (Reza-Paul et al., 2020).
At the macrosystem level, the women’s stories reflected the heavy weight of social stigma and
cultural taboos. Many described being judged morally, treated as “less deserving” of healthcare, or
excluded because of their occupation. Economic struggles made this even harder, leaving sex work
as the only option for survival while denying access to protections that others take for granted. Such
experiences mirror UNAIDS’ (2021) observation that structural stigma and inequality are central
drivers of poor SRH outcomes. The findings here remind us that stigma is not just an attitude—it
translates into real health risks, unsafe practices, and social exclusion.
Finally, the chronosystem came into sharp focus through the impact of the COVID-19 pandemic.
Women reported losing income, facing restrictions on movement, and having less power to
negotiate safe practices with clients. This temporary disruption magnified existing inequalities and
revealed how fragile access to SRH services can be in times of crisis. Similar observations have
been made globally, showing how pandemics disproportionately affect already marginalized groups
(Reza-Paul et al., 2020).
Overall, the findings highlight that improving FSWs’ SRH cannot be done by focusing on individuals
alone. Solutions must address stigma in clinics, strengthen peer-led support, and build stronger
partnerships between communities, NGOs, and health institutions. At the same time, wider policy
and cultural changes are needed to challenge stigma and provide better economic and social
protections. Viewing these issues through an ecological lens makes it clear that only multi-level
interventions—addressing personal, social, institutional, and structural factors together—will lead to
lasting improvements.
References - Bronfenbrenner, U. (1979). The Ecology of Human Development. Harvard University
Press. - Kerrigan, D., Kennedy, C. E., & Morgan-Thomas, R. (2015). A community empowerment
approach to the HIV response among sex workers. The Lancet, 385(9963), 172–185. - Reza-Paul,
S., Lazarus, L., & Jana, S. (2020). Impact of COVID-19 on sex workers in India. Journal of Social
Aspects of HIV/AIDS, 17(1), 221–224. - Scorgie, F., Nakato, D., Harper, E., et al. (2012). "We are
despised in the hospitals": Sex workers’ experiences of accessing health care in four African
countries. Culture, Health & Sexuality, 15(4), 450–465. - Shannon, K., Strathdee, S. A.,
Goldenberg, S. M., et al. (2015). Global epidemiology of HIV among female sex workers: Influence
of structural determinants. The Lancet, 385(9962), 55–71. - UNAIDS. (2021). Confronting
inequalities: Lessons for pandemic responses from 40 years of AIDS. Geneva: UNAIDS.