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. Author manuscript; available in PMC: 2023 Mar 16.
Published in final edited form as: Glob Soc Welf. 2021 May 21;8(3):251–261. doi: 10.1007/s40609-021-00213-8

Sex workers as mothers: Correlates of engagement in sex work to support children

Danielle Friedman Nestadt a,*, Ju Nyeong Park a, Noya Galai b,c, S W Beckham a, Michele R Decker d, Jessica Zemlak e, Susan G Sherman a
PMCID: PMC10019358  NIHMSID: NIHMS1878623  PMID: 36935888

Abstract

Background:

Globally, most female sex workers (FSW) are mothers but are rarely considered as such in public health and social service programs and research. We aimed to quantitatively describe FSW who are mothers and to examine correlates of current engagement in sex work to support children among a cohort of FSW in Baltimore, Maryland, United States (U.S.).

Methods:

The study utilized baseline survey and HIV/STI testing data from the Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study of women engaged in street-based sex work in Baltimore, Maryland. Variable selection and interpretation were guided by Connell’s theory of Gender and Power. We used bivariate and multivariate logistic regression analyses to examine correlates of engagement in sex work to support children among FSW mothers.

Results:

Our sample included 214 FSW with children, of whom 27% reported supporting children as a reason for the current engagement in sex work. Median age was 36 years, and mean number of children was 2.88. 20.6% were currently living with any of their minor aged children, and this was significantly more common among mothers engaged in sex work to support children (57.9% vs. 7%; p<0.001). 38.7% had ever lost legal custody of children, which was significantly less common among those supporting children through sex work (26.8% vs. 42.9%; p=0.033). In multivariate analyses, the following were independently associated with engaging in sex work to support children: African-American versus white race (aOR=2.62; 95% CI:1.18–5.82; p=0.018); less housing instability (aOR=0.42; 95% CI:0.20–0.89; p=0.024); initiating sex work at age <23 (aOR=2.59; 95% CI:1.23–5.46; p=0.012); less frequent intoxication during sex with clients (aOR=0.31; 95% CI:0.14–0.67; p=0.003); and reporting mental health as most important health concern (aOR=2.37; 95% CI:1.09–5.17; p=0.029).

Conclusions:

FSW mothers who report engagement in sex work to support children are distinct from their counterparts in key areas related to HIV and other health outcomes. Neglecting to account for this important social role may lead to missed opportunities to meaningfully promote physical and mental health and to engage women on their own terms. Future research and interventions should seek to address FSW as whole social beings and center their experiences and needs as mothers.

Keywords: sex work, motherhood, parenting, gender, power

Introduction

Globally, most cisgender women who sell sex (commonly referred to as female sex workers, or FSW) are also mothers (Willis et al., 2016). Yet, in the United States (U.S.) and elsewhere, FSW—particularly those who are street-based—are rarely viewed by public health and social service research and programs as women or mothers. They are more often considered as “vectors of disease,” “high-risk” individuals, or victims who are “forced” into this work. This view neglects to recognize them as women with complex lives and identities, of which their occupation is but one part (Vanwesenbeeck, 2001).

Public health interest in FSW is largely due to their disproportionately high burden of human immunodeficiency virus (HIV) worldwide, including in the U.S. (Baral et al., 2012; Beyrer et al., 2015; Paz-Bailey et al., 2016; Shannon et al., 2018). Prior research has identified a number of drivers of HIV among FSW that span interpersonal (e.g. inconsistent condom use), micro/work environment (e.g. policing), community (e.g. community mobilization), and macro-structural (e.g. stigma, criminalization, structural vulnerability) levels (Benoit, Jansson, et al., 2017; Deering et al., 2014; Lim et al., 2019; Reed et al., 2011; Shannon et al., 2014; Vanwesenbeeck, 2017).

Less research has focused on a nuanced understanding of why FSW initiate or continue to sex work. Both drug use and childhood abuse have been identified as factors associated with entry into sex work (Ditmore, 2013; Krumrei Mancuso & Postlethwaite, 2020; Vanwesenbeeck, 2001). However, in settings around the world, poverty has been documented as the most critical driver and an ongoing motivation for many FSW, with need for money often rooted in providing for children’s needs (Benoit, Ouellet, et al., 2017; Fielding-Miller et al., 2014; Karamouzian et al., 2016; Rosen & Venkatesh, 2008; Saggurti et al., 2011; Swendeman et al., 2015; Tsai et al., 2013).

Studies in diverse global settings have found that many FSW who are mothers emphasize the centrality of their children in their lives, and/or cite the need to support children as motivation for sex work (Bletzer, 2005; Dodsworth, 2014; Zalwango et al., 2010). However, little remains known about FSW as mothers and how or if motherhood influences behavior, HIV risk, and other health outcomes among FSW in the U.S., despite calls to center FSWs’ priorities in research and interventions (Bromwich & DeJong, 2015; Das & Horton, 2015).

A small body of primarily qualitative literature on the relationship between motherhood and sexual risk has found mixed results. Motherhood has been associated with both elevated risk (e.g. accepting more money for condomless sex to meet children’s immediate needs) (Beckham et al., 2015; Hansen et al., 2002; Rolon et al., 2013) or risk reduction (e.g., children motivating reduced drug use/sex work and increased condom use) (Basu & Dutta, 2011; Papworth et al., 2015; Servin et al., 2017). These studies are characterized by disparate definitions of motherhood, rendering comparisons difficult, and few studies have been conducted in the U.S.

Theory of Gender and Power

Connell’s theory of Gender and Power (TGP) (Connell, 1987) provides a useful framework for understanding the gendered structures in which FSW live, work, parent, and experience risk, as Beckham et al. (2015) found in Tanzania. TGP delineates three structures that interact to shape gender norms, expectations, and the division of social power: labor, power, and cathexis. TGP has rarely been applied to quantitative variables (DePadilla et al., 2011). However, Wingood and DiClemente (2000) developed a model, used to guide variable selection for the present study, that delineates health-related exposures and risk factors aligned with each TGP power structure.

Labor structures represent the gendered divisions of work, such that women’s primary role is that of mothering/nurturing, distinguishing their labor from men. This manifests for FSW in the context of limited employment opportunities and the need to provide for children, and is also reflected in measures of socio-economic status and structural vulnerability.

Power structures tend to place authority and control with men, creating power imbalance in areas such as condom negotiation and policing (Beckham et al., 2015; Wingood & DiClemente, 2000). Physical exposures, such as interpersonal violence, reflect this gendered division of power. Wingood & DiClemente (2000) include women’s and partners’ attitudes and behaviors around safer sex practices and substance use in this structure.

The last structure, cathexis, is of particular relevance to exploration of motherhood among FSW, as it relates to social norms and emotional attachments tying women’s sexuality to ideas about purity/morality (Beckham et al., 2015; Wingood & DiClemente, 2000). It manifests in family variables, psychosocial influences, and mental health (Wingood & DiClemente, 2000). The structure also reflects the socially constructed feminine practices that make one a woman, such as mothering (Connell, 2002).

Previous sociological work on motherhood has drawn the distinction between the constructs of motherhood, an immutable identity/status that comes from ever having given birth or been a mother to a child, and mothering, or the active and ongoing performance of certain tasks, such as nurturing and supporting children (McMahon, 1995). Because of our study’s emphasis on the practical, lived experiences of FSW, we focused on the latter (mothering), seeking to understand the correlates of engaging in sex work in order to support children (SWSC), one of the key tasks of “mothering”—straddling both labor and cathexis structures.

The current study aims to quantitatively describe FSW who are mothers, which has never been done in the U.S., and rarely in other settings (Reed et al., 2013; Semple et al., 2019; Servin et al., 2017), and to examine correlates of current engagement in sex work to support children (SWSC) among a cohort of FSW in Baltimore, Maryland, U.S.

Methods

Setting/Context

This study draws on baseline data from the Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, an observational prospective cohort of 250 cisgender and 62 transgender FSW recruited in Baltimore, Maryland, U.S. between April 2016 and January 2017. The study examined the role of police on the street-based sex work HIV risk environment and also included a qualitative phase with the Baltimore Police Department. As is the case in virtually all of the U.S., at the time of the study, selling sex was fully criminalized in Baltimore city. HIV prevalence in Baltimore is among the highest in U.S. cities with 2,102.1 per 100,000 residents over 13 years of age living with HIV in 2019 (Center for HIV Surveillance, 2020). The true prevalence of HIV among FSW in Baltimore is unknown, but a recent study found an HIV prevalence of 5.2% among a cohort of cisgender street-based FSW (the cohort from which the present study’s sample was drawn) in the city (Sherman et al., 2019).

Recruitment

FSW were recruited at street-based locations through targeted sampling. “Hot spots” of street-based sex work activity throughout Baltimore city were identified based on mapping of primary and secondary qualitative and quantitative data, including windshield tours and city-level arrest and 911 call data. These were translated into a targeted sampling frame with 14 recruitment zones and accompanying days of the week and times of day for each location. Recruitment was conducted in all identified venue-day-time blocks, during which research staff approached women and screened those who were interested in participating in a research study on the study van. (Allen et al., 2019; Sherman et al., 2019).

Eligibility criteria were: (1) age ≥ 15 years (all participants in the sample for the present paper were 18 years or older); (2) sold or traded oral, vaginal or anal sex “for money or things like food, drugs or favors”; (3) picked up clients on the street or at public places ≥ 3 times in the past 3 months; and (4) willing to undergo HIV and sexually transmitted infection (STI) testing. Participants who consented completed a standardized 50-minute interviewer-administered computer assisted personal interview (CAPI) and HIV/STI testing and received $70 for baseline visits. Given the sensitive nature of many of the survey questions, the vulnerability of the population, and the accompanying possibility of re-trauma, study staff told participants during the informed consent process (and during the interview, as appropriate) that they could choose not to answer a question or end the interview at any time, offered breaks during interviews, were available to talk/listen, and were able to offer information about and referrals to services in the community, as needed. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. The present paper includes baseline data on the 250 cisgender FSW in the SAPPHIRE cohort, with primary analyses focused on 214 women who reported having any living biological children. Although some women might also have been caring for non-biological children, including grandchildren (United States Census Bureau, 2020), the survey did not capture other types of caregiving relationships (see “Limitations”).

Measures

Unless otherwise noted below, “recent” describes past three months.

Gendered division of labor

Our operationalization of the labor structure was informed by the literature and included socio-economic factors and measures of structural vulnerability (Brantley et al., 2017; Wingood & DiClemente, 2000). We examined race (white, African-American, or other [including Hispanic]), relationship status (in a relationship or married vs. single), educational attainment (less than grade 12 vs. at least high school diploma/GED), recent housing instability (homelessness or moving 3+ times in three months vs. no homelessness and fewer moves), recent food insecurity (experiencing hunger more than once a week vs. once a week or less), and financial insecurity (having no recent income from full- or part-time jobs other than sex work or any recent savings vs. having non-sex work employment or savings). Participants were also asked whether they had received any recent income from public assistance, child support, a romantic/sexual partner (not for sex), or family or friends, resulting in four binary (yes/no) variables. Age of sex work initiation and length of street-based sex work engagement were dichotomized at the sample’s medians, 23 years old and five years, respectively. Recent sex work frequency was examined using a binary (yes/no) variable for daily engagement.

Participants were asked to select reasons for currently selling sex among a set of options, including “to support my children”—the study’s outcome of interest. The question resulted in a series of binary (yes/no) variables indicating whether or not each participant reported SWSC and each of the following options: to get drugs, to cover basic living expenses (food, a place to stay, bills, or extra spending money), to support non-paying sexual partner(s) or non-child family members, to pay off a debt, and because they lacked other job opportunities.

Gendered division of power

Using responses to items estimating average frequency of recent condom use during vaginal or anal sex with clients, a binary (yes/no) variable representing recent condomless vaginal or anal sex was generated. Baseline surveys included substance use frequency items based on our previous work (Brantley et al., 2017; Park et al., 2018), and binary variables were generated for recent daily use of powdered/crack cocaine or heroin and for any binge drinking in the past 12 months. Based on existing literature regarding mothers engaged in sex work (Servin et al., 2017; Zalwango et al., 2010), frequency of intoxication during recent sex with clients and recent receipt of more money for condomless vaginal or anal sex (yes/no) were explored. Participants who reported being high or drunk during sex with clients most times or always in the past three months were coded as “yes” for recent intoxicated (“drunk or high”) client sex. Emerging research has highlighted the influence of policing on sex worker health and safety outcomes, as well as the complex gendered power dynamics involved (Footer et al., 2019; Footer et al., 2016; Sherman et al., 2015), and we also explored two law enforcement-related variables: any past incarceration and arrest in the past 12 months (both binary yes/no variables).

Cathexis

Surveys included a number of additional items related to motherhood and mothering that we assessed, including number of living children to whom they had given birth, whether any of their children under 18 lived with them, and whether they had ever lost legal custody of any children.

As a reflection of mental health, depression was measured using the 20-item Center for Epidemiologic Studies Depression scale (Radloff, 1977) (CES-D), which assesses depressive symptomatology in the past week. Higher scores indicate greater symptomatology, and scores of 16 or higher were classified as “moderate to severe depressive symptoms.” Participants were also asked to report their most important health concern, and we created a binary variable for reporting mental health as the most important health concern versus all others.

HIV and STI

HIV status was ascertained via rapid oral HIV tests (OraQuick Advanced Rapid HIV-1/2 test kit, OraSure Technology Ltd, Bethlehem, PA), which have nearly perfect sensitivity and specificity (Pai et al., 2012). Biological specimens, collected via self-administered vaginal swabs, were tested for gonorrhea, chlamydia and trichomoniasis.

Statistical analysis

The sample was restricted to women who reported having any living children at baseline (85.6%; n=214/250). We conducted descriptive analyses comparing the baseline characteristics of women who did and did not report SWSC using Pearson’s χ2 tests or Fisher’s exact tests for binary and categorical variables, and two-sample t-tests for continuous variables (Table 1). We then conducted bivariate logistic regression analyses to estimate associations between each factor and reporting SWSC. Given the limited quantitative literature in this area and our desire to widely consider variables that might confound associations between other variables and SWSC, all variables significant at the p≤0.20 level in bivariate analyses were considered for inclusion in a multivariate model, also controlling for age. Final covariate selection was based on the literature and Akaike’s Information Criterion (AIC) value using the best subsets variable selection procedure in Stata (gvselect), which estimates AIC for all possible subsets of variables under consideration for inclusion to identify the most parsimonious (lowest AIC) model. Results are shown as odds ratios (OR) and 95% confidence intervals. All analyses were conducted using Stata/MP 15.1 (College Station, TX).

Table 1:

Baseline characteristics, by reported current engagement in sex work to support children (N=214)

Total Current sex work to support children
N=214 No (N=157; 73%) Yes (N=57; 27%)
Age, median (IQR) 36 (30, 42) 36 (31, 43) 35 (30, 42)
Gendered Division of Labor (Socio-economic Factors)
Race**
 White 141 (65.9%) 113 (72.0%) 28 (49.1%)
 African-American 52 (24.3%) 30 (19.1%) 22 (38.6%)
 Hispanic or Other 21 (9.8%) 14 (8.9%) 7 (12.3%)
Married or in a relationship 73 (34.3%) 52 (33.3%) 21 (36.8%)
Highest education level less than grade 12 109 (50.9%) 79 (50.3%) 30 (52.6%)
Housing instability, past 3 months* 142 (66.4%) 111 (70.7%) 31 (54.4%)
Food insecurity (hungry > once per week), past 3 months 117 (54.7%) 91 (58.0%) 26 (45.6%)
Financial instability, past 3 months* 176 (82.2%) 135 (86.0%) 41 (71.9%)
Other sources of income, past 3 months:
• Public assistance (N=213) 113 (53.1%) 79 (50.3%) 34 60.7%)
• Child support (N=213) 9 (4.2%) 4 (2.6%) 5 (8.9%)
• Money from partner (not for sex; N=213) 58 (27.2%) 40 (25.5%) 18 32.1%)
• Money from family/friends (not for sex; N=213) 87 (40.9%) 62 (39.5%) 25 (44.6%)
Sex Work Characteristics
Age started sex work ≤ 23 years* 99 (46.3%) 65 (41.4%) 34 (59.6%)
≤5 years in street-based sex work 101 (47.2%) 74 (47.1%) 27 (47.4%)
Daily sex work 139 (65.0%) 108 (68.8%) 31 (54.4%)
Gendered Division of Power (Physical Factors)
Sexual Risk & Substance Use
Condomless sex with clients, past 3 months 79 (36.9%) 63 (40.1%) 16 (28.1%)
Daily heroin or cocaine use, past 3 months** 176 (82.2%) 136 (86.6%) 40 (70.2%)
Binge drinking, past 12 months 73 (34.1%) 52 (33.1%) 21 (36.8%)
More money for condomless sex, past 3 months 38 (18.4%) 31 (20.5%) 7 (12.7%)
Most times/always drunk or high during sex with clients past 3m** 165 (77.5%) 130 (83.3%) 35 (61.4%)
Law Enforcement
Ever incarcerated 150 (70.4%) 116 (73.9%) 34 (60.7%)
Arrested in the past 12 months 101 (47.4%) 73 (46.8%) 28 (49.1%)
Cathexis (Social Factors)
Motherhood Characteristics
Number of children, mean (SD) 2.88 (1.57) 2.82 (1.59) 3.07 (1.51)
Lives with any children under 18** 44 (20.6%) 11 (7.0%) 33 (57.9%)
Ever lost legal custody of a child* 82 (38.7%) 67 (42.9%) 15 (26.8%)
Mental Health
Moderate to severe depressive symptoms (CESD≥16) 136 (64.8%) 104 (67.5%) 32 (57.1%)
Mental health most important health concern 55 (25.7%) 36 (22.9%) 19 (33.3%)
HIV & STI
Positive chlamydia or gonorrhoea test 42 (20.6%) 28 (18.9%) 14 (25.0%)
Positive HIV rapid test 10 (4.7%) 7 (4.5%) 3 (5.3%)
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*

p<0.05

**

p<0.01

Results

Baseline characteristics

The sample’s baseline characteristics are displayed in Table 1. The median age was 36 years, one-third (34.3%) was in a relationship or married, about half had graduated high school or equivalent (49.1%), and two-thirds were white (65.9%). The mean number of children was 2.88, and 27% (n=57) reported SWSC. Among all mothers, 20.6% reported currently living with any of their minor aged children and 38.7% had ever lost legal custody of children. Living with children was significantly more common among mothers who reported SWSC (57.9% vs. 7%; p<0.001), while history of custody loss was significantly less common (26.8% vs. 42.9%; p=0.033).

African-American mothers were significantly over-represented among mothers who reported SWSC (38.6% of SWSC versus 24.3% of sample; p=0.006). Mothers who reported SWSC were also significantly less likely to report recent housing instability (54.4% vs. 70.7%; p=0.026) and financial insecurity (71.9% vs. 86.0%; p=0.017). Nearly two-thirds of mothers who reported SWSC had initiated sex work at the age of 23 years or younger compared to less than a half of mothers who did not (59.6% vs. 41.4%; p=0.018).

Recent daily heroin or cocaine use was highly prevalent in the sample (82.2%), but was significantly less prevalent among mothers who reported SWSC (70.2% vs. 86.6%; p=0.005), as was frequent intoxication during sex with clients (61.4% vs. 83.3%; p<0.001). Past incarceration was less prevalent among those who reported SWSC, though the difference fell short of statistical significance (60.7% vs. 73.9%; p=0.064). Mothers who reported SWSC were more likely to have an STI (25% vs. 18.9%; p=0.34) and to report mental health as their primary health concern (33.3% vs. 22.9%; p=0.12), but differences were not statistically significant.

Reasons for current engagement in sex work

Those who reported SWSC reported various other concurrent reasons for current engagement in sex work. Table 2 presents frequencies of clusters of reasons, stratified by SWSC status. Getting drugs was the most commonly reported reason for current sex work across both groups. It was less common, although not significantly so, among women who reported SWSC (78.9% vs. 87.9%; p=0.10). All other reasons, economic in nature, were significantly (p<0.05) more likely to be reported by those who reported SWSC: to cover basic living expenses (82.5% vs. 63.1%); because they had no other job opportunities (24.6% vs. 8.3%); to pay off a debt (21.1% vs. 8.3%); and to support regular sex partners or non-child relatives (14% vs. 3.2%). Examining clustering of current reasons for sex work other than SWSC and to get drugs, those who reported SWSC were more likely to report multiple other reasons for sex work, with the most common combinations being basic living expenses/paying off a debt and basic living expenses/no other job opportunities (each 12.3% of the SWSC group).

Table 2:

Reasons for current engagement in SW, by report of current engagement in sex work to support children (N=214)

Total Current sex work to support children
N=214 No (N=157; 73%) Yes (N=57; 27%)
Current reasons for sex work (not mutually exclusive):
• To get drugs 183 (85.5%) 138 (87.9%) 45 (78.9%)
• Basic needs/living expenses (food, place to stay, extra spending money, pay bills)** 146 (68.2%) 99 (63.1%) 47 (82.5%)
• No other job opportunities** 27 (12.6%) 13 (8.3%) 14 (24.6%)
• To pay off a debt* 25 (11.7%) 13 (8.3%) 12 (21.1%)
• To support regular sex partner(s) or non-child family members** 13 (6.1%) 5 (3.2%) 8 (14.0%)
Patterning of non-drug concurrent reasons for sex work^:
• Drugs only 59 (93.7%) 51 (94.4%) 8 (88.9%)
• Expenses only 97 (45.3%) 74 (47.1%) 23 (40.4%)
• Job only 4 (1.9%) 3 (1.9%) 1 (1.8%)
• Partner/family only 1 (0.5%) 1 (0.6%) 0 (0.0%)
• Expenses & partner/family 6 (2.8%) 3 (1.9%) 3 (5.3%)
• Expenses & debt 19 (8.9%) 12 (7.6%) 7 (12.3%)
• Expenses, partner/family & debt 1 (0.5%) 0 (0.0%) 1 (1.8%)
• Expenses & job 15 (7.0%) 8 (5.1%) 7 (12.3%)
• Expenses, partner/family & job 3 (1.4%) 1 (0.7%) 2 (3.5%)
• Expenses, debt & job 3 (1.4%) 1 (0.7%) 2 (3.5%)
• Expenses, partner/family, debt & job 2 (0.9%) 0 (0.0%) 2 (3.5%)
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^

Reasons abbreviated: “job”=no other job opportunities; “expenses”=to cover basic living expenses (food, place to stay, pay bills, extra spending money); “partner/family”=to support regular sex partner(s) or non-child family members; “debt”=to pay off a debt

*

p<0.05

**

p<0.01

Associations with current engagement in sex work to support children

In the multivariate model (Table 3), the following variables were independently associated with SWSC: African-American versus white race (aOR=2.62; 95% CI:1.18–5.82; p=0.018); less housing instability (aOR=0.42; 95% CI:0.20–0.89; p=0.024); initiating sex work at age ≤23 (aOR=2.59; 95% CI:1.23–5.46; p=0.012); less frequent intoxication during sex with clients (aOR=0.31; 95% CI:0.14–0.67; p=0.003); and reporting mental health as most important health concern (aOR=2.37; 95% CI:1.09–5.17; p=0.029).

Table 3:

Correlates of current engagement in sex work to support children (logistic regression models)

Bivariate Logistic Regression Multivariate Model^
Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI)
Gendered Division of Labor
Race
• White REF REF
• African-American 2.96 (1.49, 5.89)** 2.62 (1.18, 5.82)*
• Hispanic or Other 2.02 (0.74, 5.47) 1.53 (0.51, 4.64)
Housing instability 0.49 (0.26, 0.92)* 0.42 (0.20, 0.89)*
Financial insecurity 0.42 (0.20, 0.87)* 0.48 (0.21, 1.10)
Started sex work 23 years or younger 2.09 (1.13, 3.88)* 2.59 (1.23, 5.46)*
Daily sex work 0.54 (.29, 1.01) --
Gendered Division of Power
Daily heroin or cocaine use 0.36 (0.18, 0.75)** --
High/drunk most times have sex with client 0.32 (0.16, 0.63)** 0.31 (0.14, 0.67)**
Ever incarcerated 0.55 (0.29, 1.04) --
Cathexis
Mental health primary health concern 1.68 (0.86, 3.27) 2.37 (1.09, 5.17)*
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^

Multivariate model adjusted for age, in addition to all variables in model.

*

p<0.05

**

p<0.01

Discussion

The study is one of the first to quantitatively examine correlates of selling sex to support children, which has important global significance. While more than one-quarter of mothers in our sample reported SWSC, this aspect of a woman’s motivation/need to engage in sex work is rarely considered in literature on FSW. TGP and its structures are helpful “tools for thinking,” as we seek to contextualize our results (Connell, 2002; Connell, 1987). For FSW, the overlapping and intersecting nature of the gender structures described by Connell may be particularly pronounced. As a group, they are defined by both their labor and gender, and their occupation places them outside their expected economic position and violates the social construction of what it is to be a woman. In the discussion that follows, we acknowledge and accept that our results reflect that overlap, rather than being easily compartmentalized into one structure versus another.

In the realm of cathexis, our study also sheds light on the experiences of biological motherhood and mothering among this population more broadly. Although a majority of the cohort were mothers, only a small minority lived with any of their biological children, which may be a reflection of the high prevalence of drug use in the sample, as a large proportion of out-of-home child welfare placements in the U.S. are a result of parental substance use (U.S. Department of Health and Human Services, 2018). Even among mothers who reported SWSC, less than two-thirds had children living with them. This also suggests that the work of mothering and supporting children does not always include living together. Co-residence has been used in other FSW studies as a proxy for motherhood (Servin et al., 2017), which might not be an appropriate proxy in U.S. settings. More than one-third of mothers in our cohort had ever lost legal custody of a child, including more than a quarter of mothers who reported SWSC. This high prevalence of child removal is consistent with other FSW studies in North America, where custody loss has also been tied to resulting declines in maternal mental and physical health (Duff et al., 2011; Kenny et al., 2019; Wall-Wieler et al., 2017).

Our findings suggest that women who reported SWSC experience some heightened vulnerability, with that vulnerability largely rooted in labor. They were significantly more likely to be African-American, which may be a reflection of entrenched economic gender and racial disparities in Baltimore, where African-American households are twice as likely as white households to be living in poverty (CFED, 2017). Median annual earnings among African-American women in Baltimore in 2017 were approximately 40% less than among white women (National Partnership for Women & Families, 2018), such that African-American mothers may have even more limited employment options, lower earning potential, and heightened financial instability, potentially driving engagement in sex work. In bivariate analyses, SWSC was associated with also engaging in sex work to support sexual partners and other family members, to cover basic living expenses, to pay off debt, and because of lack of other job opportunities. These reasons cluster in various combinations that reflect the complexities of supporting oneself and one’s children.

However, our findings also suggest that FSW engaging in SWSC may be less structurally vulnerable and less likely to engage in some risky behaviors compared to other FSW mothers, reflected in factors across all three TGP structures. Housing instability and financial insecurity were less prevalent among them, as were daily drug use (bivariate only) and frequent intoxication during sex with clients. Seeking to contextualize these findings in prior qualitative research on FSW who are mothers, one hypothesis that emerges is a possible assertion of personal agency in the face of structural vulnerabilities and the work of providing for children. These women may be seeking to reframe or resist stigma associated with sex work and prove their capacity to be “good” mothers given social, economic, and structural constraints that may create a seemingly impossible bind (Benoit, Jansson, et al., 2017; Ma et al., 2019).

Nearly two-thirds of our sample were categorized as having moderate to severe depressive symptomatology, which is aligned with literature from the U.S. and other settings regarding the very high prevalence of depressive symptomatology among FSW and poor mental health as both a driver of engagement in sex work and an outcome associated with some of the risks of sex work, including violence (Alegria et al., 1994; Beattie et al., 2020; Park et al., 2019; Surratt et al., 2005). Although CES-D scores did not differ significantly between mothers who did and did not report SWSC, mothers who reported SWSC did have more than double the odds of reporting mental health as their most important health concern (Hutton et al., 2004; Meade & Sikkema, 2005). This may reflect some other underlying psychological distress that is distinct from depression. Managing life as both a mother and a sex worker is complex (Ma et al., 2019). Several studies have reported that the contrast between the socially valued role of mother and the deep stigma of sex work can lead mothers engaged in sex work to experience dual-role stress or strain (Beckham et al., 2015; Brennan, 2004; Castañeda et al., 1996; Sloss et al., 2004; Zalwango et al., 2010). They may struggle to construct an integrated identity when being a good mother requires providing for children but engaging in sex work to do so may classify one as a “bad” mother (Dodsworth, 2014; Ma et al., 2019). This highlights the inherent constraints on mothers who sell sex produced by the structures of both labor and cathexis. A recent study on the relationship between maternal role strain and depression among FSW in Mexico found that parental strain was significantly associated with greater depressive symptomatology, but the dimension of strain related to feelings of guilt and shame about sex work was not (Semple et al., 2019). Stigma, role strain, and how they may affect health and behavior warrant further exploration, especially as there is evidence that FSW mothers may avoid services for fear that providers will judge them or remove their children (Duff et al., 2015; McClelland & Newell, 2008; Murnan et al., 2020; Sloss et al., 2004), which may impact the wellbeing of mothers and children.

Limitations

These findings should be considered in light of some limitations. Motherhood and mothering are complex constructs that manifest in numerous ways, many of which are difficult to measure quantitatively. We selected SWSC as an operationalization of mothering and the labor of providing for one’s children, but acknowledge that this is only one dimension of motherhood, and there may be mothers in this cohort who are actively involved in childrearing but not supporting their children through sex work. Similarly, our sample only included women with biological children, which may have excluded women who are presently or have been equivalent caregivers to non-biological children. Because this was a cross-sectional study and we did not collect data on the timing of having children, loss of custody, or drug use patterns, we were unable to assess temporality of the associations. Previous literature suggests, for example, that drug use might both drive custody loss and other situations that limit financial support of children and increase once a mother is no longer caring for/supporting her children (Bletzer, 2005; Dodsworth, 2014; Rolon et al., 2013). Whether sex work is a job mothers continued after having children or one they began specifically to help support children could have important implications, and we were unable to assess this. The stigma surrounding sex work and drug use, especially in the context of motherhood, and the sensitive nature of other self-reported survey items increase the possibility of response or social desirability bias.

Implications for Policy and Practice

Women who are both FSW and mothers are an often-overlooked group who are distinct from other FSW in a number of ways, and nearly a quarter of our sample was engaged in SWSC. Neglecting to account for this important social role may lead to missed opportunities to meaningfully promote physical and mental health and to engage women on their own terms. Sex worker-driven community mobilization projects in other settings have evolved to become more family-centered based on the needs and priorities of the FSW in those communities, and family-centered services, including health clinics, childcare, night schools, cultural activities, civic engagement/advocacy, children’s shelters, banking/financial programs, and strengthening of peer support networks have been associated with improved outcomes for both children and FSW (Ali et al., 2021; Ali et al., 2014; Basu & Dutta, 2011; Beard et al., 2010; Pardeshi & Bhattacharya, 2006). Our finding that, for many FSW, sex work is a means to earn a living and support their children adds to the mounting evidence of the detrimental effects of criminalizing sex work (Vanwesenbeeck, 2017). For mothers engaged in SWSC, effects of arrest, incarceration, and having a criminal record extend to children and families, disrupting family processes, livelihoods, and caregiving, and potentially limiting future employment and other opportunities (CAP Poverty Team et al., 2020). Decriminalization and the treatment of sex work as work are key steps toward easing sex work stigma and could also have an enormous impact on these mothers’ ability to not be defined by the role of “sex worker,” potentially reducing role strain (Ali et al., 2021; Weitzer, 2018).

Conclusions

This study adds to the limited global literature on mothering among FSW, revealing that FSW who are engaged in sex work in order to support their children are distinct from their counterparts in some key areas that are related to HIV and other health outcomes, including protective behaviors related to drug use and sex work and greater concerns about mental health. In future research, quantitative findings, such as the increased concern for mental health, should be explored qualitatively to better understand the mechanisms underlying the relationships, including the role of various types of stigma and how children may motivate reductions in drug use, in order to inform intervention. As we seek a true understanding of FSWs’ behaviors, health, and the risks they face in the context of an illegal sex market, it is critical that we view them as social beings who are part of families, communities, and societies, who occupy a number of other social roles, and who are significant not simply because they may transmit or be at high risk of disease but because they are human beings whose health, well-being, and families matter in their own right.

Acknowledgements:

This work was supported by the National Institute of Drug Abuse under Grant R01DA038499-01 and the Johns Hopkins Center for AIDS Research under Grant 1P30AI094189. Note: The funders had no role in study design, data collection, or in analysis and interpretation of the results, and this article does not necessarily reflect views or opinions of the funder. We thank the SAPPHIRE research staff, community advisory board, and the women who participated in the study.

Footnotes

Competing interests: Dr. Sherman is an expert witness for plaintiffs in opioid litigation.

Ethics approval and consent to participate: All participants provided voluntary, written, informed consent to participate. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Availability of data and materials:

The datasets generated and/or analysed during the current study are not publicly available due due to their containing information that could compromise the privacy of research participants but are available from the senior author, SGS (ssherman@jhu.edu), on reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analysed during the current study are not publicly available due due to their containing information that could compromise the privacy of research participants but are available from the senior author, SGS (ssherman@jhu.edu), on reasonable request.

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