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Study population
The 40 FSWs interviewed had a mean age of 32 years (range: 21–44 years) and half were brought up in rural areas. All participants had some form of basic education, 11 participants had completed secondary school and three received higher education. Thirty-three participants had been married or had cohabited with a sexual partner. However, at the time of the interview, only four were married or were living with a partner. Furthermore, half of the study participants commenced sex work between 18 and 24 years old and four started before age 18. Most participants had children and the majority of them had their first child before entry into sex work. Nine participants were HIV positive with seven testing positive after entry into sex work (Table 1).
Understanding of mental health
In terms of participants’ knowledge of mental health, five said they had no idea how to define mental health. For example, when one participant was asked what comes to her mind when she hears about mental health, she said:
“I do not know. Does it mean someone is healed?” (MF 113).
However, although most participants could not provide a clear definition of mental health, based on their personal and second-hand experiences they could link it with stress (Dhiki, n = 23), depression (Msongo wa mawazo, n = 17), insanity (Pagawa, n = 16), suicide (Kujitia kitanzi, n = 6) and harmful substance use (Madawa za kulevya, n = 3). Other descriptions included someone being mentally disturbed or having mental issues (kusumbuka akili) and excessively ruminating (kufikiria sana). Respondents who were interviewed either wholly or partially in English also defined mental health as ‘craziness’ or ‘madness’ (referring to ‘insanity’), described as being hospitalised or wandering the streets collecting rubbish. However, other participants linked it with witchcraft (Uchawi/urogin = 7) or physical illnesses (Ugonjwa wa kimwilin = 2) such as STIs (Magongwa ya zinaa) and diabetes (Kisukari). The words in brackets were the local terms they used to describe mental health.
The quotes below illustrate how study participants defined mental health, with some linking it to mental health problems such as stress, insanity, and suicide:
“[it is]a person who is insane. I am okay because I am not crazy. People are known to be crazy when they start walking naked or speaking to themselves” (MF 186).
“Maybe you have piled too much stress in your mind that you are defeated you don’t have direction, you are just there. You could even be crossing, and you get hit by a car and you are just there. It is like you are there and you are not there” (MF 497).
“They become mad. Let us say someone has disagreed with her husband. Her husband chased her with all the children, and you do not know where to begin, food etc. and you do not have a job, thoughts come to your mind…until you think of committing suicide”
(MF 208).
Participants were also specifically asked if they could define ‘depression’ and most linked it with stress, with several respondents using the two terms interchangeably and often described as ‘thinking too much’ (Kufikiri sana). However, some participants (n = 6) distinguished between mental health as a clinical condition and depression as societal stress. Below are the responses from two participants who were asked if depression is a mental illness:
“Depression is when one is stressed. While mental sickness is when one is insane. With mental sickness, the brain is not functioning well. While with depression the brain is functioning okay, but you are stressed” (MF 113).
“It is not madness. It is something disturbing her in the mind but not madness. There is a problem” (MF 017).
Determinants of mental ill-health
Of the 40 FSWs interviewed, 28 described personal experiences of poor mental health, whether described as mental health issues, stress, depression, or PTSD; seven women reported previous suicidal ideation. All but one of these participants narrated the factors that they perceived precipitated the mental health episode. The most reported risk factor was intimate partner violence, followed by poverty, sex work-related risks such as violence from clients, or the death of a family member. Infrequently mentioned factors included physical disability and harmful substance use. We mapped the reported risk factors against i) social factors, ii) gender disadvantage factors, iii) sexual risk factors and iv) physical health, as the four main distal determinants of suicide and mental health among FSWs, depicted by the conceptual framework Fig. 1.
- I)
Social Factors
The main themes that emerged in relation to social risk factors for poor mental health were poverty and family bereavement. These findings are presented below.
Poverty
Poverty among FSWs was described as a key social determinant influencing poor mental health and thoughts of suicide among FSWs. Out of the 28 respondents who narrated their own mental health experiences, eight of them specifically linked it with poverty. Almost all of them were once married or cohabited with a partner and had one or more children, although none of them received child support from the fathers of their children after being divorced or separated. Relationship breakdown plunged them into poverty. Several of them had no parents and received no support from relatives. As the sole source of income, respondents struggled to provide basic needs for themselves and their children, such as food and school fees, and they struggled to care for other family members. Some respondents reported having to borrow money to provide for their children’s basic needs:
“Those are very tough times because issues follow each other like you have not paid rent, books are needed and no food. It can really be very bad. I am alone without a penny and I have nobody to assist me, so I look for where to borrow money” (MF 033).
Reports of mental health problems such as suicidal thoughts, being stressed and depressed due to financial challenges were frequently narrated:
“I had thought I will buy poison; I kill all my children and I kill myself and life would end. Now I did not have even the money (to buy poison). Now I said if I get even thirty bob (shillings), I will ask how much Rat kill is, and I give all my children and I drink also and we all die at night” (MF 497).
“Sometimes I feel like running away from that house. Because you find that there is nobody to help me. Then I ask myself, if I go my grandmother will struggle so much and she might die. Here again is my younger brother, what will happen to him if I go? There are times you get very broke like weekdays. You wonder what to do because, these old people are looking up to you; they need to eat, to pay rent, yes” (MF 240).
Furthermore, as highlighted by the conceptual framework, poverty influences other determinants of poor mental health such as higher risk sexual behaviours and increased risk of violence (Fig. 1). Findings in this study demonstrated that most of the women who reported poverty as the main cause of their poor mental health experiences explained how financial stress and their desire to care for their children, motivated them to start sex work. Several of them did not complete their secondary education, could not find a better job for survival, and received no financial support. Their only option was to sell sex for ‘quick money’, which had the potential to further increase their vulnerability to poor mental health:
“You see I was not getting support from anybody and remember my mother had thrown me out maybe if she supported me, I could not have gone into sex work. By the way, this job I was not introduced to it by anybody. I was not very bright, and this was the only way out to get quick money. So, I started going to the bar and that is how I started sex work” (MF 033).
Death of a family member
The impact of the death of loved ones on FSWs’ mental well-being surfaced in the interviews. Some respondents reported symptoms of stress and depression following the death of a family member especially when the deceased had provided financial support. Reports of financial stress after the death of a spouse or parent(s) were recounted by some women, this precipitated their entry into sex work as they had no other means of survival. For example, when one of the participants was asked about depression, she explained:
“Me I would say I am like that (that she is depressed). I used to have so many more thoughts than normal because I don’t have my people. Here is my child and I had to do this job (sex work). Sometimes when I think about it, I just cry. I would imagine if I had my parents or my family, I would not do this work” (MF 0208).
Another participant wept during the interview as she told how she was alone with her children when her husband who used to provide for them had died:
“By 2017 my husband died and left me alone: I am alone bringing up my children [weeps]. It has been very difficult because when my husband died, they (husband’s relatives) took everything from me and only left me with a bed” (MF 0547).
As a coping mechanism, a participant explained that she had started using cannabis to assist her to recover from the tragic death of her husband who was murdered by an unknown assailant:
“Then I would cry a lot, nowadays I don’t. Plus I also learnt something, you know when you go through so much pain you get something to relieve yourself. I smoke a lot of cannabis, me I smoke a lot of cannabis. It helps me with those challenges now” (MF 0569).
The family of her late husband accused her of being the killer of her husband, which added to her stress.
- II)
Gendered Disadvantage
Intimate partner violence was the most reported gendered disadvantage causing mental health problems among respondents.
Intimate partner violence (IPV)
All the IPV-related mental health problems narrated by respondents occurred during their previous relationships before sex work commencement. Almost half (n = 11) of the participants who reported experiencing poor mental health linked it to their previous experiences of IPV. Previous IPV also accounted for the highest number of participants reporting suicidal thoughts (4 out of 7). Other mental health symptoms due to IPV were also reported, such as depression, PTSD and living in fear.
Although respondents narrated the experience of IPV in all forms (i.e., physical, verbal, emotional, economic, and sexual violence), physical violence was the most frequently reported. Several women described how they were beaten and verbally abused by their previous intimate partners. For example, one woman explained how she was beaten by her husband until he broke her leg. Respondents described social norms that sanction a man’s right to assault a wife physically and sexually, and that society expects women to endure the pain husbands inflict. As such, some described how they had to stay in their marital homes with abusive partners until they could not handle the stress of the marriage anymore. All the 11 respondents who reported IPV from their previous partners either asked for a divorce or escaped from their marriages/relationships to start a new life with their children.
The quotes below illustrate respondents’ explanations of how their IPV experiences affected them mentally and led to suicidal thoughts:
“Instead of giving you love, he gives you beating. So when you reflect you even have suicidal thoughts like I used to look at myself and wonder I don’t have a mother and I am suffering with these children I feel that death was a better option” (MF 0393).
“I would feel like even killing myself. I used to think about going back home but I told you that my grandmother used to tell me that a woman is to endure. Now I am enduring, and if I go home what will I say” (MF 520).
Reports of being frustrated and stressed due to IPV were also described:
“I even looked old because of stress and many frustrations. This person (husband) is with you in the house and he does not want to look for a job other than sitting at home. So you even wonder what is happening. Just try asking whether he will go to work and he will rain blows on you” (MF 0004).
Furthermore, because of the notion that a woman should endure pain, and since several respondents were either orphans or raised by a single parent, they could not rely on family members so had to look for their accommodation and survive alone after separating from their husbands. All women except one had children with their intimate partners so starting life over again with their children was a challenge as they received no support from the fathers of their children. This resulted in several of them entering sex work for survival since most had not completed school and couldn’t find a job that could provide for their needs and that of their children. Despite their financial struggles, several respondents vowed never to return to their ex-husbands:
“We (respondent and children) used to sleep down on the mattress because I did not have a bed and I had sworn that come rain or sunshine I can never go back to that man who had married me. I needed peace and so I could not go back. That is how my job started (sex work) and I would go to the clubs looking for clients and I did very well and I was able to support my child” (MF033).
- III)
Sexual risk factors
In terms of sexual risk factors, issues related to sex work were the most commonly reported theme and it was the third most reported perceived cause of poor mental health experiences among respondents. Almost all respondents who related their poor mental health to sex work-related risk factors either got into sex work due to poverty, mainly after the experience of IPV or the death of close family members. This illustrates the interrelationships between the distal factors of suicide and mental health as illustrated in the conceptual framework.
Sex work-related
Despite sex work being a good source of income for most respondents, it was noted as a stressful and risky job. Some respondents described sex work-related mental health challenges, such as violence from clients refusing to pay after sex or being beaten and forced into condom-less sex. In addition to risks from clients, reports of the city Askaris (police) chasing FSWs and demanding to be bribed in cash or through sex were narrated. These experiences significantly affected respondents psychologically:
“When you are arrested by the Council (police) it is a risk because you will be arrested and the Council police will want to sleep with you, he sleeps with you and he does not pay you and he will still take you to court” (MF 0012).
“Once you are found on the streets walking, whether it is the police or Council you will have to go (being chased away)” (MF 0012).
One respondent narrated being stressed and living in fear for her life due to her work:
“Me I tell you this sex work job, sometimes it gives me stress. If I had been stabbed or hurt, I think about if I die because of this job who would be left with this child. I just think about many things” (MF 0208).
In addition, the mental health impact of not knowing one’s HIV status after forced condomless sex with a client was narrated by two respondents. One of the respondents said she did not go to the hospital when the incident happened as she was not aware of her options to reduce her risk of HIV. However, the other respondent did go to the hospital for post-exposure prophylaxis although she struggled to take the pills as she found them too big. She threw them in the toilet when her client tested HIV negative. Below are the quotes for the two respondents narrating their mental health experiences following a condomless sex encounter:
“Basically I was unhappy and restless. I was stressed so much so people noticed. He (regular client) even noticed and would tell me ‘babe you seem so stressed’, I told him it’s because I didn’t know my status or yours” (MF 0113).
“I felt like my heart was burning. It affected me so much because I was wondering whether he had infected me with the virus, or with sexually transmitted diseases, or what does he want with me, is he a devil worshipper or what, uh! For a number of days, I was feeling I don’t want to go to work, I would stay like that bored” (017).
Lastly, sex work also exposes FSWs to violence and stigma in their communities, which is the reason why a lot of FSWs tend to hide their job from neighbours and family members. Reports of FSWs being physiologically affected by the stigma they experienced in their communities were narrated. The quote below shows a description of a respondent’s experience of verbal abuse from a neighbour and how that affected her:
“Psychological (violence) is when you find someone is insulting you before your own children calling you a prostitute. ‘You prostitute’ and such before your children. So sometimes you just suffer alone” (MF 0058).
- IV)
Physical Health Factors
In relation to the fourth domain of the conceptual framework, only a few women related their poor mental health to physical disabilities or harmful substance use. These findings are presented below.
Physical health and disability
A few study participants (n = 3) perceived poor physical health or disability as the cause of their mental health issues. This included one participant losing an eye when a client hit her with a soda bottle and another who had an elongated growth around her labia, which she linked with reconstructive surgery she had after being raped at 3 years old. Interestingly, the stress of living with HIV was mentioned by only one participant.
The woman who lost her eye described how her disability affected her mental wellbeing:
“I was used to using my two eyes so after I lost one eye it was very stressful when crossing the road because I was not used to using one eye to check if the road is clear. I used to get very stressed and like where I stayed, there was a highway so I used to wait for people so that we can cross the road together and other times I could hold someone’s hand so that we cross the road together. It took me a while to get used to using one eye and I was stressed for about one year to acclimatize” (MF033).
Harmful substance use
Although several women described their use of alcohol and other harmful substances such as cannabis and bhang for courage and as a coping mechanism while at sex work, only one participant explicitly linked it to poor mental health. The participant claimed to have nearly killed her child due to drug use:
“I held that child and I wanted to kill him, I held a knife and said this thing why is it stressing me. When I held the knife like this, I felt a sharp cut in my heart, my senses came back and I asked myself, God, what do I want to do? So I was like if I kill this child, I am the one with a problem” MF 423).
The woman panicked and she promised herself to never smoke cannabis again.
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