title: Sexual violence against female sex workers in The Gambia: a cross-sectional examination of the associations between victimization and reproductive, sexual and mental health.
abstract: BACKGROUND
  Female sex workers (FSW) are a vulnerable population for sexual violence and poor sexual and reproductive health outcomes. Sexual violence against FSW has not been widely studied in The Gambia. This study will report the prevalence of and evaluate the health issues correlated with forced sex perpetrated by clients against FSW in The Gambia, and will secondly aim to inform future research and efforts to improve health outcomes for survivors of violence.
  
  
  METHODS
  A cross-sectional survey was administered among 251 FSW accrued through a combination of chain referral and venue-based sampling in The Gambia. Eligibility criteria included being over 16 years old and having exchanged sex for money, goods, or favors in the past 12 months.
  
  
  RESULTS
  There is a high prevalence of sexual violence against FSW in The Gambia, with 29% (n = 70) of participants reporting a client forced them to have sex in their lifetime. Women who reported forced sex by a client were more likely to report symptoms of depression (aOR 2.15, CI: 1.10-4.16 p < 0.05), unwanted pregnancy (aOR: 2.69, CI: 1.12-6.49 p < 0.05) and report "no", "difficult" or "somewhat difficult" access to condoms (aOR: 3.31, CI: 1.76-6.26 p < .01) compared to women who did not report forced sex. Client-perpetrated forced sex was also negatively associated with receiving any sexually transmitted infection (STI) test in the past 12 months (aOR: 0.49, CI: .26-.91 p < .05).
  
  
  CONCLUSIONS
  FSW who experience sexual violence by a client are more likely to experience poor sexual, reproductive and mental health outcomes. Responding to sexual violence among FSW, including providing survivors with access to post-exposure prophylaxis, emergency contraception, and mental health services, must be a priority given the prevalence of forced sex and links with poor health outcomes. Efforts to reduce sexual violence against FSW is a vital strategy to improve the health and safety of FSW as well as impact the spread of HIV/STIs in The Gambia.
authors.affiliation: Johns Hopkins School of Public Health, 615 N Wolfe St. #5041, Baltimore, MD, 21205, USA. jenifersherwood@gmail.com.
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Sherwood
authors.affiliation: Johns Hopkins School of Public Health, 615 N Wolfe St. #5041, Baltimore, MD, 21205, USA. agrosso@jhpsh.edu.
authors.forename: Ashley
authors.initials: A
authors.lastname: Grosso
authors.affiliation: Johns Hopkins School of Public Health, 615 N Wolfe St. #5041, Baltimore, MD, 21205, USA. mdecker@jhsph.edu.
authors.forename: Michele R
authors.initials: MR
authors.lastname: Decker
authors.affiliation: Johns Hopkins School of Public Health, 615 N Wolfe St. #5041, Baltimore, MD, 21205, USA. speitzme@jhsph.edu.
authors.forename: Sarah
authors.initials: S
authors.lastname: Peitzmeier
authors.affiliation: Johns Hopkins School of Public Health, 615 N Wolfe St. #5041, Baltimore, MD, 21205, USA. epapwort@jhuccp.org.
authors.forename: Erin
authors.initials: E
authors.lastname: Papworth
authors.affiliation: Enda Santé Senegal, 56, Comico VDN, BP, 3370, Dakar, Sénégal. dioufda@endatiersmonde.org.
authors.forename: Daouda
authors.initials: D
authors.lastname: Diouf
authors.affiliation: University of Gaston Berger, P.O. Box 17470, St Louis, Sénégal. fatou-maria.drame@ugb.edu.sn.
authors.forename: Fatou Maria
authors.initials: FM
authors.lastname: Drame
authors.affiliation: Lilunga House, Fifth Floor, Somhlolo Street, Mbabane, Swaziland. ceesayn@unaids.org.
authors.forename: Nuha
authors.initials: N
authors.lastname: Ceesay
authors.affiliation: Johns Hopkins School of Public Health, 615 N Wolfe St. #5041, Baltimore, MD, 21205, USA. sbaral@jhsph.edu.
authors.forename: Stefan
authors.initials: S
authors.lastname: Baral
mesh_terms: D000293:Adolescent; D000328:Adult; D019548:Crime Victims / Q000523:psychology*; D003430:Cross-Sectional Studies; D005260:Female; D005714:Gambia; D006297:Health Services Accessibility; D006801:Humans; D008603:Mental Health; D008875:Middle Aged; D056990:Post-Exposure Prophylaxis; D011247:Pregnancy; D011275:Pregnancy, Unwanted; D015995:Prevalence; D060728:Reproductive Health; D012742:Sex Offenses / Q000523:psychology* / Q000706:statistics & numerical data; D060386:Sex Workers / Q000523:psychology; D011795:Surveys and Questionnaires; D055815:Young Adult