Investigating how structural factors affect vulnerability to violence and risk reduction among sex workers in Peru

The health effects of physical violence are well documented, but we know less about how psychological abuse and discrimination affect well-being, particularly mental health. Globally, sex workers face violence from clients, boyfriends, pimps and police. This abuse is not only physical but also psychological and ‘symbolic‘ - including more subtle harms such as discrimination and social stigma. We need to understand how these different forms of violence affect sex workers‘ ability to protect themselves against other risks, including HIV, drug use, stress and depression, to improve the health and wellbeing of this marginalised population.
Peru is an excellent case study to research these issues. A recent survey shows that violence against sex workers is very common in this setting, and many sex workers are not aware of their rights. This study will use a mix of research methods, analysing existing survey data and carrying out interviews with sex workers, policy-makers and service providers, to investigate how discrimination affects sex workers‘ vulnerability to violence, and their capacity to protect their physical and mental health. This study will provide crucial evidence for public health interventions which aim to reduce violence and improve the health of sex workers globally.

Sex workers face multiple physical and mental health risks, including violence, HIV, coercion, drug use, stress and depression. Despite widespread abuse, sex workers have received little attention in global reviews of violence. Violence can have severe physical and emotional health consequences and increases vulnerability to HIV. Stigma may further exacerbate vulnerability to physical and psychological violence, and affect emotional health and capacity to manage risk.
The World Health Organization advocates violence reduction interventions among sex workers. Structural approaches - which address social, environmental and political factors - are considered crucial for HIV prevention. The concept of ‘structural violence‘ provides a framework to study the consequences of different forms of violence, physical, emotional and ‘symbolic‘ (such as stigma). Peru has among the highest rates of domestic violence globally and a high prevalence of abuse against female sex workers, providing an excellent case study to investigate how structural factors bring about and sustain physical, emotional and symbolic violence, and affect capacity to manage risk - an under-researched area.
Aim: To investigate how structural factors affect vulnerability to violence and mediate capacity for risk reduction among male, female and transgender sex workers in Peru.
Objectives:
(1) To examine associations between structural factors, physical, emotional and symbolic violence among sex workers
(2) To explore pathways through which structural, physical, emotional and symbolic violence mediate capacity to manage emotional health and other risks among sex workers
(3) To analyse how key agencies mediate structural factors which affect the risk of violence among sex workers
Methods: A mixed methods study, set in Peru, comprising:
A) A systematic literature review of the risk of violence among sex workers globally, followed by a secondary analysis of data from the ‘Sex Worker Empowerment Survey‘ in Peru, examining associations between structural factors, violence and other health outcomes; B) a qualitative study of structural factors affecting risk of violence, how different forms of violence interact, and how these affect capacity to manage health risks, using in-depth interviews with sex workers; and C) a stakeholder analysis to explore key agencies‘ perspectives on structural determinants of violence among sex workers, and their potential role in mediating these factors, using semi-structured interviews.
Outputs: Findings will inform structural interventions to reduce violence and other health risks among sex workers globally, as well as feeding directly into national policy in Peru. This study will also identify scope for further research addressing the structural context of risk.