Vulnerable Exposures and Outcomes of Children of Female Sex Workers in Low-and Middle-income Countries: Application of bioecological vulnerability framework

Swarna D.S. Weerasinghe^1*Meghan Fitzgerald²Emily K. Perttu²Brian Wills²Wendy L. Macias-Konstantopoulos³

• ¹Dalhousie University Department of Community Health and Epidemiology, Halifax, Canada
• ²Global Health Promise, Portland, United States
• ³Massachusetts General Hospital Department of Emergency Medicine, Boston, United States

Children of female sex workers (CFSW) are exposed to unique bioecological vulnerabilities, negatively affecting their developmental outcomes. We interviewed 1,280 female sex worker mothers (FSWM) in eight low-and middle-income countries (Angola, Brazil, South Africa, Democratic Republic of Congo, India, Indonesia, Kenya, and Nigeria) between January 16 and October 1, 2019. This exploratory study focused on multilayered exposures from early childhood to adolescence resulting in maldevelopment and other negative outcomes for CFSW, as reported by mothers. We used Bronfenbrenner's revised Bioecological System Theory of Human Development as our analytical framework. The interview data contained both numerical responses and short answers. Quantitative information was summarized using prevalence estimates, and textual information was coded and grouped into major categories using inductive coding. FSWM reported outcomes varied across countries but supported complex interaction within and between the micro-, meso-, exo-and macro systems, described by the theoretical framework. Findings included CFSW exposure to suboptimal childcaring and rearing environments and a high prevalence of adverse outcomes including the majority of (61%, country range 45-67%) daughters entering sex work at an early age (14 years, country range 13.5-18 years), both sons and daughters experiencing physical harm (72%, range 21-85%) and sexual abuse (sons 57%, daughters 74%). Daughters were introduced to sex work as a mode of survival, out of necessity. The FSWM reported outcomes include bioecological vulnerabilities that impeded their sons' development, and protective environments that supported sons' healthy development. These were categorized as: 1) vulnerabilities associated with high risk living environments such as brothels, hot spots and on the street where they were exposed to sex work; 2) negative psychological, physical, and behavioral outcomes including becoming criminals, victims and perpetrators of abuse and 3) protective environments of living away from the mothers work and finding informal work that may mitigate the harmful effects of bioecological vulnerable exposures. The CFSW experienced significant threats to healthy development, contributing to adverse physical and psychological developmental outcomes. These findings underscore the urgent need for evidence-based policy directives, interventions, and support.