ABSTRACT
Background and Aim
Female sex workers are an undeniable and often overlooked part of our society. Due to their hidden nature, they can pose potential risks to our communities. This study aims to shed light on the high‐risk sexual behaviors of female sex workers in Fars province.
Methods
In this cross‐sectional study, we enrolled 196 female heterosexual sex workers. We collected information through interviews. Qualitative variables were reported in numbers and percentages, while quantitative variables were described. We used logistic regression models and multivariate analysis.
Results
The results showed that a significant number of sex workers engaged in risky behaviors. Alcohol and drug use were prevalent among the participants, with 73.8% and 77.3% reporting alcohol and drug use, respectively. Sex workers who were never married and current smokers (70.8% and 69.7%) were more likely to engage in oral sex and anal intercourse. Furthermore, our findings revealed that 58.2%, 56.6%, and 47.4% of female sex workers had a history of oral, anal, and both oral and anal sex, respectively. Moreover, younger sex workers (under 20 years old) had a higher prevalence of anal and oral sex compared to other age groups. Living in high‐level areas (66.7%) and the city center (75.0%) was associated with a higher likelihood of engaging in oral and anal sex. Lastly, the rates of STD and HPV infection were higher among this population.
Conclusion
Smoking, alcohol and drug/substance use, never married status, and having more customers per day were identified as risk factors for engaging in oral sex and anal intercourse among female sex workers. The prevalence of these behaviors among sex workers in Fars province is alarmingly high, especially among younger individuals.
Keywords: alcohol, drug users, HPV, Iran, prevalence, risk factors, risky behavior, sex workers
1. Introduction
Sex workers are an undeniable yet hidden part of our society, which poses potential risks for these communities. One major concern is their potential role in spreading sexually transmitted diseases due to their contact with multiple partners, with no special services provided for their protection. The risk of HIV infection in female sex workers is about 13.5 times higher than that of women of reproductive age in the general population [1]. This hidden and hard‐to‐reach population plays a key role in the expansion of HIV infection because of their risky behaviors. The population of female sex workers (FSWs) in Iran has been estimated as 228,700 (95% CI 153,500; 294,300) and the prevalence of HIV among them in 2015 was estimated at 4.5% [2].
Unfortunately, due to Iran's Islamic government and the prohibition, condemnation, and punishment of prostitution in the religion, obtaining information about this group is very challenging. Sexually transmitted infections are a significant public health challenge worldwide, causing acute illness, infertility, long‐term disability, and even death. In fact, they are as common as diarrheal diseases, malaria, and respiratory diseases, occurring at the same rate each year [3]. Researchers believe that the rate of sexually transmitted diseases is increasing day by day. The prevalence of bacterial and viral sexually transmitted diseases worldwide is estimated to be more than 125 million cases per year, with 86% occurring in developing countries. These diseases can have severe medical and psychological consequences for millions of men and women. Notably, studies conducted in Africa and Asia consistently show that female sex workers and their clients account for 80%–90% of sexually transmitted diseases [4]. In a study by Nasirian et al. in Isfahan, Iran, 84.9% of FSWs reported STI symptoms, N gonorrhoeae, HPV, or T vaginalis infected 12.1% of them [5].
High‐risk behaviors such as unprotected sex, multiple sexual partners, drug abuse, and engaging in oral and anal sex are common among female sex workers. Unfortunately, financial incentives and customer requests often result in these individuals willingly or unwillingly engaging in these risky behaviors. Research indicates that sexually transmitted infections, especially the risk of HPV infection, are twice as prevalent among female sex workers compared to women in the general population [6]. The numbers paint an even more concerning picture as we get into specific behavioral patterns. Tehran's data reveals that 77% of female sex workers knew their high HIV risk, yet 98% didn't use condoms regularly [7].
Additional studies provide alarming statistics. Heterosexual anal sex (HAS) could be one of the causes of the HIV spread more than oral sex [8]. In 2013, one‐third of heterosexuals in the United States reported engaging in anal intercourse within the previous 12 months. Furthermore, in 2015, statistics showed that up to 33% of women and 38% of men in the U.S. had experienced anal intercourse at some point in their lives. Similar trends were observed in Australia, where 25.3% of men and 19.3% of women reported engaging in anal intercourse [9]. About 18.5% of FSWs above 18 years old reported anal intercourse in Iran and 80% of them had non protective contact [10]. Another study in Iran examined the challenges and experiences of Iranian prostitutes and found that the main themes were: experiencing violence, health risks, social exclusion, objectification, and lack of social and legal support structure, which can contribute to concealment and worsen the spread of diseases [11].
Studies have shown that heterosexual individuals engaging in anal and oral intercourse have higher rates of infections such as gonorrhea and chlamydia [12]. Additionally, these individuals also have significantly higher rates of HPV infection in both the anal and oral regions compared to the general population. The study in Lubumbashi, Democratic Republic of the Congo shows that young female sex workers engaged in anal sex have a significantly higher risk of being HIV‐positive. The risk of HIV transmission through anal sex is 16–18 times greater than penile‐vaginal intercourse [13]. This evidence underscores the importance of prioritizing the healthcare of sex workers to combat the spread of sexually transmitted diseases. This may involve increased examination, vaccination, treatment, education, and the implementation of special policies, although health workers are less willing to provide services to this group [14, 15]. Achieving the World Health Organization's goal of eliminating sexually transmitted diseases by 2030 requires particular attention to high‐risk groups such as sex workers, making it crucial to determine their sexual behaviors and the prevalence of sexually transmitted diseases.
Due to the lack of detailed research on unconventional sexual behaviors (such as oral and anal intercourse) and their connection to other high‐risk behaviors like alcohol and drug consumption and smoking in Iran, this study was conducted to investigate high‐risk sexual behaviors among female sex workers in Fars province.
2. Materials and Methods
In Shiraz, two Women's Health Centers provide free personal protective equipment such as condoms, health education, and periodic check‐ups to these individuals. Since it is difficult to access these individuals in our country—due to religious and political restrictions—it was decided to have the checklist completed by the clients of these centers. According to experience, the personnel of these centers are trusted by sex workers and provide better answers to their questions (perhaps due to the relationship and information that the personnel have about them). The checklists regarding high‐risk sexual behaviors in this group, were prepared as multiple‐choice and open‐ended questions. Individual identifiable characteristics were removed so that individuals could not be identified. The center expert was fully trained about how to complete the checklist. Before interviewing the individuals, they complete a consent form. Then, 196 checklists were completed through face‐to‐face interviews conducted by experts of the center who were willing to participate in the study.
2.1. Eligibility Criteria
Inclusion criteria:
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Having sex in exchange for receiving money, goods, services or drugs.
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Iranian citizenship
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Residing in Shiraz
Exclusion criteria:
The people who did not want to be interviewed or provided incomplete information to the questions were excluded from the study.
2.2. Definitions
2.2.1. Female Sex Worker
FSWs are a group of women who provide sexual services for economic gain.
2.2.2. Risky Behavior
The following three behaviors were considered high‐risk behaviors.
2.2.2.1. Smoking
Tobacco smoking is the practice of burning tobacco with the smoke inhaled to be tasted and absorbed into the bloodstream [16].
2.2.2.2. Drug/Substance Abuse
Use of a drug/substance in a way that is detrimental to self, society, or both. This definition includes both physical dependence and psychological dependence. These substances include opioids, hypnotics and sedatives, stimulants, hallucinogens, volatile hydrocarbons, and cannabinoids.
2.2.2.3. Alcohol Consumption
Consuming—orally—no more than one or two drinks (ethanol) per day, and if drinking to the point of drunkenness or not [17].
2.2.3. Oral Sex (Fellatio)
Stimulation of a man's penis by his partner's mouth—usually by licking or sucking.
2.2.4. Anal Sex (Intercourse)
A type of carnal behavior wherein enjoyment is attained via the introduction of the penis into the anus [18].
2.3. Ethical Approval
This study was approved by the Ethics Committee of Shiraz University of Medical Sciences, Fars, Iran, with code: IR.SUMS.REC.1401.144. Individual identifiable characteristics were removed so that individuals could not be identified. Before interviewing the individuals, they completed a consent form.
2.4. Sample Size Estimation
In this cross‐sectional study, the sample size was estimated to be 244 based on the Cochran formula in a restricted population with Z = 1.96, p = 38%, q = 62%, and d = 1.6p. After correction, the final sample size was estimated to be 196.
2.5. Statistical Analysis
Qualitative variables were described as numbers and percentages, while quantitative variables were reported as mean ± standard deviation (SD). To determine factors associated with sexually risky behaviors, including oral and anal sex, a logistic regression model was used. Variables with a p value of less than 0.2 in a simple logistic regression model were entered into the multivariate analysis. Then, using the backward elimination method, nonsignificant variables were removed from the model one by one. In this study, a significance level of less than 0.05 was considered (tests were two‐sided). The data were analyzed using SPSS Statistics software version 22 and GraphPad Prism software version 9.
3. Results
A total of 196 FSWs were included in the study. Out of these, 114 (58.2%) reported a history of oral sex, 111 (56.6%) reported a history of anal sex, and 93 (47.4%) reported a history of both oral and anal sex. The mean age of participants was 35.96 ± 9.98. Participants who engaged in both oral and anal sex were younger compared to those who did not engage in these behaviors. Figure 1 shows the prevalence of oral and anal sex based on age groups. The highest prevalence was found among participants below 20 years, with 92.0%.
Figure 1.
Prevalence of sexually risky behaviors based on age groups in female sex workers.
In terms of other behaviors, 45.4% of FSWs were current smokers, 42.9% were alcohol users, and 11.2% were drug users. The prevalence of oral and anal sex was higher among participants living in high‐level areas (66.7%) and the city center (75.0%) compared to other areas. Participants who were never‐married had a higher prevalence of oral and anal sex (81.1%) compared to other participants. The prevalence was also higher among FSWs with a high school degree (75.0%) and academic education (73.7%). Additionally, the prevalence of oral and anal sex was higher among FSWs who were smokers (70.8% and 69.7%), alcohol users (73.8% and 73.8%), and drug users (77.3% and 72.7%) compared to those without a history of these risk factors. Participants with a history of oral and anal sex had a higher prevalence of sexually transmitted diseases (STDs) compared to those without these behaviors. Among the 66 FSWs who had undergone HPV testing, 57 (86.4%) were found to be HPV positive. Furthermore, the prevalence of HPV was higher among participants with a history of oral (93.8%) and anal (92.8%) sex compared to those without these behaviors. Additional socio‐demographic and behavioral characteristics of female sex workers based on their engagement in risky behaviors can be found in Tables 1 and 2.
Table 1.
Socio‐demographic characteristics of female sex workers by risky behaviors.
| Variables | Oral sex | Anal sex | ||
|---|---|---|---|---|
| No | Yes | No | Yes | |
| N = 82 (41.8%) | N = 114 (58.2%) | N = 85 (43.3%) | N = 111 (56.6%) | |
| Age (mean ± SD) | 39.94 ± 9.22 | 33.11 ± 9.55 | 39.46 ± 8.18 | 33.29 ± 10.43 |
| Place of residence | ||||
| City center | 7 (35.0) | 13 (65.0) | 5 (25.0) | 15 (75.0) |
| Downtown | 50 (49.5) | 51 (50.5) | 51 (50.5) | 50 (49.5) |
| High‐level area | 25 (22.3) | 50 (66.7) | 29 (38.7) | 46 (61.3) |
| Marital status | ||||
| Never married | 7 (18.9) | 30 (81.1) | 7 (18.9) | 30 (81.1) |
| Married | 25 (53.2) | 22 (46.8) | 26 (55.3) | 21 (44.7) |
| Temporarily married/living with partner | 6 (37.5) | 10 (62.5) | 8 (50.0) | 8 (50.0) |
| Divorced | 27 (36.5) | 47 (63.5) | 30 (40.5) | 44 (59.5) |
| Widowed | 17 (77.3) | 5 (22.7) | 14 (63.6) | 8 (36.4) |
| Education | ||||
| Illiterate (no education) | 5 (83.3) | 1 (16.7) | 3 (50.0) | 3 (50.0) |
| Primary school | 24 (68.6) | 11 (31.4) | 23 (65.7) | 12 (34.3) |
| Guidance school | 14 (48.3) | 15 (51.5) | 15 (51.7) | 14 (48.3) |
| High school | 8 (25.0) | 24 (75.0) | 12 (37.5) | 20 (62.5) |
| Diploma | 19 (33.9) | 37 (66.1) | 22 (39.3) | 34 (60.7) |
| Academic | 12 (31.6) | 26 (68.4) | 10 (26.3) | 28 (73.7) |
| Having children | ||||
| No | 16 (26.2) | 45 (73.8) | 17 (27.9) | 44 (72.1) |
| Yes | 66 (48.9) | 69 (51.1) | 68 (50.4) | 67 (49.6) |
| Other jobs | ||||
| No | 67 (42.4) | 91 (57.6) | 69 (43.7) | 89 (56.3) |
| Yes | 15 (39.5) | 23 (60.5) | 16 (42.1) | 22 (57.9) |
Note: Data reported as number (percentage).
Table 2.
Behavioral characteristics of female sex workers by risky behaviors.
| Variables | Oral sex | Anal sex | ||
|---|---|---|---|---|
| No | Yes | No | Yes | |
| N = 82 (41.8%) | N = 114 (58.2%) | N = 85 (43.3%) | N = 111 (56.6%) | |
| Age at first sex(mean ± SD) | 32.49 ± 8.09 | 26.83 ± 8.56 | 32.68 ± 8.27 | 26.53 ± 8.28 |
| Smoking | ||||
| No | 53 (53.5) | 46 (46.5) | 55 (55.6) | 44 (44.4) |
| Previous consumption | 3 (37.5) | 5 (62.5) | 3 (37.5) | 5 (62.5) |
| Consumption now | 26 (29.2) | 63 (70.8) | 27 (30.3) | 62 (69.7) |
| Alcohol consumption | ||||
| No | 54 (57.4) | 40 (42.6) | 58 (61.7) | 36 (38.3) |
| Previous consumption | 6 (33.3) | 12 (66.7) | 5 (27.8) | 13 (72.2) |
| Consumption now | 22 (26.2) | 62 (73.8) | 22 (26.2) | 62 (73.8) |
| Drug abuser | ||||
| No | 73 (45.6) | 87 (54.4) | 75 (46.9) | 85 (53.1) |
| Previous consumption | 4 (28.6) | 10 (71.4) | 4 (28.6) | 10 (71.4) |
| Consumption now | 5 (22.7) | 17 (77.3) | 6 (27.3) | 16 (72.7) |
| Duration as a sex worker | ||||
| ≤ 1 year | 9 (36.0) | 16 (64.0) | 14 (56.0) | 11 (44.0) |
| 2–5 years | 34 (39.1) | 53 (60.9) | 38 (43.7) | 49 (56.3) |
| 6–10 years | 25 (38.5) | 40 (61.5) | 22 (33.8) | 43 (66.2) |
| ≥ 11 years | 14 (73.7) | 5 (26.3) | 11 (57.9) | 8 (42.1) |
| Customers diversity | ||||
| Consistent | 24 (53.3) | 21 (46.7) | 23 (51.1) | 22 (48.9) |
| Inconsistent | 58 (38.4) | 93 (61.6) | 62 (41.1) | 89 (58.9) |
| Condom use for sex with clients | ||||
| Consistent | 52 (46.0) | 61 (54.0) | 60 (53.1) | 53 (46.9) |
| Inconsistent | 21 (42.0) | 29 (58.0) | 16 (32.0) | 34 (68.0) |
| At the customer's request | 8 (26.7) | 22 (73.3) | 8 (26.7) | 22 (73.3) |
| Never | 1 (33.3) | 2 (66.7) | 1 (33.3) | 2 (66.7) |
| Number of sex per day | 2 (2–3) | 3 (2–5) | 2 (2–3) | 3 (2–5) |
| HPV vaccine | ||||
| No | 78 (42.9) | 104 (57.1) | 83 (45.6) | 99 (54.4) |
| Yes | 4 (28.6) | 10 (71.4) | 2 (14.3) | 12 (85.7) |
| Having STD | ||||
| No | 30 (36.6) | 24 (21.1) | 31 (36.5) | 23 (20.7) |
| Yes | 52 (63.4) | 90 (78.9) | 54 (63.5) | 88 (79.3) |
| Having HPV (N = 66) | ||||
| No | 7 (20.6) | 2 (6.3) | 7 (17.5) | 2 (7.7) |
| Yes | 27 (79.4) | 30 (93.8) | 33 (82.5) | 24 (92.3) |
Among the FSWs, 32 (16.2%) reported always receiving oral sex requests from their partners, while 21 (10.7%) reported always receiving anal sex requests. Among the 114 FSWs who seldom or usually engaged in oral sex, 17 (14.9%) reported always using condoms. Similarly, among the 111 FSWs who seldom or usually engaged in anal sex, 15 (13.5%) reported always using condoms. Among FSWs with a history of both oral and anal sex, 54 (47.4%) reported engaging in oral sex more than five times in the last month, while 36 (32.4%) reported engaging in anal sex more than five times in the last month. These findings are summarized in Table 3. Table 4 presents the findings of a simple regression analysis on factors related to sexually risky behaviors. The results show that FSWs who were older, had a higher age at their first sexual experience, had been working in the industry for a longer time, and were married, divorced, or widowed, had significantly lower odds of engaging in oral sex. Conversely, FSWs with higher levels of education, inconsistent clients, smokers, alcohol users, drug users, and those who had a higher number of sexual encounters per day had significantly higher odds of engaging in oral sex. In addition, FSWs who were older, had a higher age at their first sexual experience, lived in downtown areas, and were married, temporarily married or living with a partner, divorced, or widowed, had significantly lower odds of engaging in anal sex. On the other hand, FSWs with higher levels of education, smokers, alcohol users, and those who had a higher number of sexual encounters per day had significantly higher odds of engaging in anal sex.
Table 3.
Sexually risky behaviors in female sex workers.
| Variables | N (%) | Variables | N (%) |
|---|---|---|---|
| Oral sex request from partners | Anal sex request from partners | ||
| Never | 7 (3.6) | Never | 5 (2.6) |
| Usually | 82 (41.8) | Usually | 75 (38.3) |
| Most of the time | 75 (38.3) | Most of the time | 95 (48.5) |
| Always | 32 (16.3) | Always | 21 (10.7) |
| Having oral sex | Having anal sex | ||
| Never | 82 (41.8) | Never | 85 (43.4) |
| Seldom | 47 (24.0) | Seldom | 43 (21.9) |
| Usually | 67 (34.2) | Usually | 68 (34.7) |
| Condom use in oral sex (n = 114) | Condom use in anal sex (n = 111) | ||
| Seldom | 71 (62.3) | Seldom | 67 (60.4) |
| Usually | 26 (22.8) | Usually | 29 (26.1) |
| Always | 17 (14.9) | Always | 15 (13.5) |
| Number of oral sex in the last month (n = 114) | Number of anal sex in the last month | ||
| Less than 3 times | 39 (34.2) | Less than 3 times | 57 (51.4) |
| 3–5 times | 21 (18.4) | 3–5 times | 18 (9.2) |
| More than 5 times | 54 (47.4) | More than 5 times | 36 (32.4) |
Table 4.
Simple regression analysis of factors related to sexually risky behaviors.
| Variables | Oral sex | Anal sex | ||
|---|---|---|---|---|
| OR (95% CI) | p value | OR (95% CI) | p value | |
| Age | 0.92 (0.89–0.95) | > 0.001* | 0.93 (0.90–0.96) | > 0.001* |
| Age at first sex | 0.92 (0.89–0.96) | > 0.001* | 0.91 (0.88–0.95) | > 0.001* |
| Education | 1.49 (1.21–1.83) | > 0.001* | 1.39 (1.14–1.70) | > 0.001* |
| Place of residence | ||||
| City center | Ref | — | Ref | — |
| Downtown | 0.55 (0.20–1.49) | 0.24 | 0.32 (0.11–0.96) | 0.043* |
| High‐level area | 1.07 (0.38–3.07) | 0.89 | 0.53 (0.17–1.61) | 0.262 |
| Marital Status | ||||
| Never married | Ref | — | Ref | — |
| Married | 0.20 (0.07–0.56) | 0.002* | 0.18 (0.07–0.50) | > 0.001* |
| Temporarily married/living with partner | 0.38 (0.10–1.43) | 0.15 | 0.23 (0.06–0.84) | 0.03* |
| Divorced | 0.40 (0.15–1.04) | 0.06 | 0.34 (0.13–0.88) | 0.02* |
| Widowed | 0.07 (0.02–0.25) | > 0.001* | 0.13 (0.04–0.44) | 0.001* |
| Duration as a sex worker | 0.89 (0.83–0.96) | 0.004* | 1.01 (0.94–1.07) | 0.78 |
| Number of sex per day | 1.65 (1.28–2.12) | > 0.001* | 1.64 (1.28–2.11) | > 0.001* |
| Customers diversity | ||||
| Consistent | Ref | — | Ref | — |
| Inconsistent | 1.83 (0.97–3.58) | 0.07 | 1.50 (0.76–2.92) | 0.23 |
| Smoking | ||||
| No | Ref | — | Ref | — |
| Previous consumption | 1.92 (0.43–8.47) | 0.389 | 2.08 (0.47–9.20) | 0.33 |
| Consumption now | 2.79 (1.52–5.10) | > 0.001* | 2.87 (1.53–5.23) | > 0.001* |
| Alcohol consumption | ||||
| No | Ref | — | Ref | — |
| Previous consumption | 2.70 (0.93–7.80) | 0.067 | 4.18 (1.37–12.73) | 0.01* |
| Consumption now | 3.80 (2.01–7.18) | > 0.001* | 4.54 (2.39–8.61) | > 0.001* |
| Drug abuser | ||||
| No | Ref | — | Ref | — |
| Previous consumption | 2.09 (0.63–6.96) | 0.23 | 2.20 (0.66–7.32) | 0.19 |
| Consumption now | 2.85 (1.01–8.10) | 0.04* | 2.35 (0.87–6.32) | 0.09 |
Abbreviation: CI, confidence interval.
Significant at 0.05 level.
The results of the multivariate regression analysis on factors related to sexually risky behaviors are presented in Table 5. According to these results, younger age (OR: 0.96; CI 95%: 0.92–0.99), higher levels of education (OR: 1.35; CI 95%: 1.06–1.71), a higher number of sexual encounters per day (OR: 1.34; CI 95%: 1.01–1.77), and drug use (OR: 3.27; CI 95%: 1.02–10.51) were significantly associated with engaging in oral sex. Furthermore, a higher number of sexual encounters per day (OR: 1.32; CI 95%: 1.01–1.75), current alcohol consumption (OR: 2.72; CI 95%: 1.31–4.60), and past alcohol consumption (OR: 3.38; CI 95%: 1.07–10.69) were significantly associated with engaging in anal sex.
Table 5.
Multivariate regression analysis of factors related to sexually risky behaviors.
| Outcome | Variables | OR (95% CI) | p value |
|---|---|---|---|
| Oral sex | Age | 0.96 (0.92–0.99) | 0.03* |
| Education | 1.35 (1.06–1.71) | 0.01* | |
| Number of sex per day | 1.34 (1.01–1.77) | 0.04* | |
| Drug abuser | |||
| No | Ref | — | |
| previous consumption | 1.50 (0.37–5.93) | 0.56 | |
| Consumption now | 3.27 (1.02–10.51) | 0.04* | |
| Anal sex | |||
| Age | 0.96 (0.93–1.003) | 0.07 | |
| Number of sex per day | 1.32 (1.01–1.75) | 0.04* | |
| Alcohol consumption | |||
| No | Ref | — | |
| previous consumption | 3.38 (1.07–10.69) | 0.04* | |
| Consumption now | 2.72 (1.31–5.60) | 0.007* |
Abbreviations: CI, confidence interval; OR, odds ratio.
Significant at 0.05 level.
4. Discussion
High‐risk behaviors among female sex workers, such as unprotected sex, having multiple partners, drug abuse, and engaging in oral and anal sex, are a serious societal threat. The behaviors involving oral and anal sex are particularly dangerous due to the higher risk of transmitting STDs.
Our study found that 58.2% of female sex workers had a history of oral sex, 56.6% had a history of anal sex, and 47.4% had engaged in both oral and anal sex. Other studies have reported similar findings. Morady et al. found a prevalence of anal/oral sex of 4.55% [19]. Kazeroni et al. conducted a study in Shiraz and reported a prevalence of anal and oral sex of 7% and 16.2%, respectively [20]. Kassaeian et al. reported a prevalence of anal and oral sex of 27.6% and 34.2%, respectively, in Esfahan [21]. The Karamozin et al. meta‐analysis showed that anal sex prevalence ranged from 3.3% to 34.2%, and oral sex prevalence ranged from 0.5% to 27.6% [22]. Non‐Iranian studies have reported oral sex prevalence ranging from 11% to 70% and anal sex prevalence ranging from 5% to 53% [23].
While our results differ from research conducted in Iran, they align with findings from foreign studies. It's important to note that in countries with restrictions on these individuals' activities, they may be less willing to report unconventional sexual behaviors. The willingness to report such behaviors can indicate trust in the interviewer's accuracy and skill. Additionally, some studies only inquire about high‐risk behaviors over a limited time period, potentially leading to underreporting.
In our study, we observed a higher prevalence of risky behaviors involving anal and oral sex among individuals under the age of 20 compared to other age groups. The prevalence of these behaviors decreased with increasing age. Jenness et al. found that unprotected anal intercourse was more common among individuals aged 30–39 [24]. Zhou et al. reported that the low‐tier FSW26‐35 age group had the highest prevalence of anal and oral sex [25]. However, we were unable to find specific research addressing this matter. The prevalence of oral and anal sex was higher among participants living in high‐level areas (66.7%) and the city center (75.0%), compared to other areas. Jenness et al. found that homeless sex workers engaged in this behavior more frequently than other sex workers [24].
In our study, similar to the findings of Jenness et al., we suggest that in prosperous areas of the city, customers may be willing to pay more for sexual services that go beyond the norm, such as oral and anal sex. And perhaps the country's severe economic problems confirm that they are willing to do anything for more money, even if it puts their health at risk. Interestingly, never‐married participants had a higher prevalence of engaging in oral and anal sex (81.1%) compared to other participants. This is in line with the study by Weiyong et al., which found that 58.4% of FSWs who had anal sex were married [26]. The Zhou et al. study also showed that unmarried sex workers had a lower risk of oral sex compared to other marital status groups [25]. Our results were consistent with these findings. Maheu‐giroux et al. found that unmarried individuals had a higher risk of engaging in anal sex compared to married sex workers [27].
Among female sex workers, having a high school degree was associated with a higher prevalence of oral sex (75.0%), while academic education was associated with a higher prevalence of anal sex (73.7%). The Zhou et al. study showed that oral sex was more prevalent among female sex workers with a junior high school education [25]. According to researchers, oral and anal sex is considered ugly and taboo in traditional and religious societies (especially Muslims). Less educated people, or in other words, older sex workers, are afraid of doing this. However, for people with secondary or university education, this issue has become somewhat more acceptable to them due to access to social media or watching pornographic films. This issue could be due to the lack of necessary training in this field for students. Since the government fundamentally does not believe in such behavior, it does not have a plan to manage it.
Among FSWs, the prevalence of oral and anal sex was higher among smokers (70.8% and 69.7%, respectively), alcohol users (73.8% and 73.8%), and drug users (77.3% and 72.7%), compared to those without a history of these risk factors or prior consumption.
We also found that the prevalence of STDs was higher among participants with a history of engaging in oral and anal sex compared to those without these risky behaviors. The Joesoef et al. study reported a rate of STDs among sex workers with oral and anal sex that was 3.5 times higher than among other sex workers [28]. However, the Iranian study did not report the relationship between oral and anal sex and STDs in sex workers, though this association is commonly seen in men who have sex with men (MSM).
Among the 66 FSWs who underwent the HPV test, 57 (86.4%) tested positive. The prevalence of HPV was higher among participants with a history of engaging in oral sex (93.8%) and anal sex (92.8%) compared to those without these risky behaviors.
Although we compared our study's results with similar studies, our study is unique, and it is necessary to study this group and their sexual and social behaviors. Our findings indicate that among sex workers in Shiraz, oral sex and anal intercourse are very common. This behavior is particularly prevalent among young sex workers, which may be due to a lack of awareness or a fear of losing their virginity. Additionally, we found that current smokers and alcohol users were more likely to engage in oral sex and anal intercourse compared to non‐smokers. Previous studies consistently show that smokers are more prone to risky behaviors [29].
Moreover, it has been observed that smokers tend to choose more hazardous professions and are exposed to a wider range of problematic behaviors compared to non‐smokers [30]. In terms of alcohol and drug/substance abuse, it is evident that individuals who consume alcohol, become intoxicated, or use substances are more prone to engaging in any type of behavior. Furthermore, it is plausible that individuals who are sex workers and addicted to substances may engage in sexual activities in exchange for drugs [31].
Regarding the association between higher education and an increased likelihood of performing oral sex and anal intercourse, it is important to consider the influence of age on this relationship. Younger individuals are more likely to engage in these behaviors, which aligns with the higher literacy levels among younger people. This suggests an indirect relationship between literacy and age.
The results of the study indicate that individuals who have a higher number of customers per day are at a greater risk of engaging in oral sex and anal intercourse. This can be attributed to the fact that these customers often have diverse demands, thereby increasing the likelihood of these behaviors occurring. It is important to note some limitations of this study. The Islamic government's prohibition of prostitution made it difficult to access this specific group of individuals. Even if we identified them, they were hesitant to participate in interviews, resulting in a limited sample size. Although we tried to alleviate the interviewees' concerns, we may not have been completely successful in this regard due to the specific circumstances of the country and religious and political restrictions. Also, since this study was limited to Fars Province, all of its results may not be generalizable to the country.
5. Conclusion
In conclusion, our study found that current smokers, alcohol and drug/substance abusers are more inclined to engage in oral sex and anal intercourse. These behaviors are particularly prevalent among female sex workers in Fars province, particularly among younger individuals. Never‐married female sex workers and those with a higher number of customers per day are also at a higher risk of engaging in these behaviors. Additionally, a history of these behaviors increases the risk of HPV and STDs.
Author Contributions
Mohammadreza Heydari: conceptualization, investigation, funding acquisition, visualization, methodology, validation, software, formal analysis, project administration, resources, supervision, data curation, writing – original draft, writing – review and editing. Maryam Nejabat: conceptualization, investigation, writing – original draft, funding acquisition, methodology, writing – review and editing, software, formal analysis, project administration, supervision, data curation, resources. Zohre Foroozanfar: methodology, validation, software, formal analysis, writing – original draft, writing – review and editing.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The corresponding author, Maryam Nejabat, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Acknowledgments
The authors appreciate all those who assisted them in the conductance of this study, particularly Shiraz women health center for help us in sampling and Shiraz University of Medical Sciences that funded this study. The authors would like to express their gratitude to all those who contributed to the execution of this study. Specifically, they would like to thank the Shiraz Women's Health Center for their assistance with sampling and the Shiraz University of Medical Sciences for providing the necessary funding. This study was supported by Vice‐Chancellor for Research of Shiraz University of Medical Sciences under code27446 and approved by Shiraz University of medical Sciences ethical issue IR.SUMS.REC.1400.842. The supporting organization did not have any role in the design of the study and collection, analysis, and interpretation of data, or in writing the manuscript. All authors have reviewed and approved the final version of the manuscript submitted for publication.
This study was conducted in the Behavioral Diseases Counseling Center at Shiraz University of Medical Sciences, Shiraz, Iran.
Data Availability Statement
The information of female sex workers is kept confidential in the relevant database, and the data are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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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 information of female sex workers is kept confidential in the relevant database, and the data are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.