A sex worker is defined as a person “who accepts money or goods for sexual services and who explicitly defines this as an income-generating activity, even if not considering sex work as his or her profession” (1). Attitudes towards sex work have always been controversial and are rather negative ranging from condemnation over tacit acceptance to compelling need. However, prejudice against sex workers predominates in most societies and often leads to discrimination and other human rights violations (2). It is likely that these circumstances also aggravate healthcare inequalities since utilization of healthcare services particularly depends on socio-economic aspects (3). Indeed, reduced utilization of healthcare has been shown for sex workers (4, 5). Given the existing prejudices in large parts of society, it is possible that these also are present in healthcare professionals. Negative experiences with healthcare providers, including anxiety associated with physical exams, discomfort with discussing sensitive topics or male doctors’ insensitivity to female sex workers’ need, are known barriers hindering healthcare utilization (6, 7). Consequently, negative attitudes towards sex workers and the anticipation of these negative attitudes by sex workers themselves may contribute to poor healthcare utilization and a reduced quality of medical care. However, research on healthcare professionals’ knowledge of and attitudes towards sex workers is sparse. Most evidence is based on surveys or interviews with sex workers themselves, rather than data acquired from healthcare providers (8). To the best of our knowledge, only two studies investigated the attitudes towards sex work in nursing and psychology students, respectively. It was shown that a feminist mindset corresponds to more negative attitudes towards sex work, that attitudes change during professional training, and that attitudes are related to willingness to care for sex workers (9, 10).

Generally, in psychology, an attitude refers to a set of emotions, beliefs, and behaviors towards a particular object, person, thing, or event (11, 12). It is suggested that there are distinct components that form attitudes. In 1998, Eagly and Chaiken described a tri-component ABC-model: affective component, behavioral, and cognitive. In brief, the affective component refers to emotional reactions or feelings an individual has towards an object, person, issue, or situation, while the behavioral component refers to how the individual behaves, or acts based on their attitude. The cognitive component refers to the beliefs, thoughts, and attributes that an individual associates with an object, person, issue, or situation. Because attitudes can influence peoples’ behavior (13), it is important to be aware of healthcare professionals’ attitudes towards sex workers. If the prevalence of prejudices represents the population average, this may significantly discourage sex workers from seeking healthcare service. In addition to an exploratory description of healthcare professionals’ general views on sex workers, we built on existing knowledge in other areas of medical research to generate the following hypotheses: (I.) Similar to trends observed in the general population, we assumed that women would rate sex work rather negative compared to men, and (II.) that older participants would rate sex work as more negative than younger ones. Besides these demographic factors, it is known that contact with stereotyped populations generally reduces stereotypes (a process called the “contact hypothesis” in social psychology) (14). We therefore hypothesized that (III.) the frequency of professional contact with sex workers would influence the attitudes towards and the medical evaluation of sex workers.

Finally, some data suggest that healthcare professionals’ base their treatment decisions not only on their expertise, but also on their attitudes (15). Consequently, we expected a similar effect in our sample and expected that healthcare professionals’ estimates of sex workers’ health risks would be influenced by their attitudes. Specifically, we hypothesized that (IV.) participants who rate sex workers as victims expect that sex workers are at higher risks for various mental and somatic conditions.

In sum, our main aim was to provide a comprehensive view on healthcare providers’ knowledge of and attitudes against sex workers in Germany.

Several studies have demonstrated a discrepancy between sex workers’ and other citizens’ utilization of healthcare services (4, 5, 24–26). However, little is known about the reasons. Prejudice of healthcare professionals against sex workers or even anticipated animosities by sex workers may explain the barriers for sex workers to utilize healthcare services at least in part. Yet, data about healthcare professionals’ knowledge of and attitudes towards sex workers has been largely missing. This study is the first to report such data for Germany.

Recently, a large population-based survey conducted in Germany assessed the attitudes of the general population towards sex workers (19). Although no formal statistical comparison between this survey and our study is possible based on the differences between questionnaires, similar aspects were evaluated. The overall results of the present study are mostly in line with the results from that survey: In our sample 45.8% of the respondents agreed (to some extend) to the statement “sex work is a job like any other” while in the general population 47% agreed to the statement “if a woman works as a prostitute by her own choosing, she has a job like any other to me.” Conversely, 55% of participants in our sample agreed (to some extend) to the statement “many sex workers are forced to do sex works” while 71% in the general population agreed to a similar statement. Finally, 89% of respondents stated that sex workers are at risk of suffering mentally because of their work compared to 69% in the sample representative for the general population. In conclusion, prejudice against sex workers seems to be as common in healthcare professionals as in the general population and was related to overestimation of prevalence for different diseases, especially mental diseases. Similar stigmatizing attitudes have been observed in healthcare professionals towards other stigmatized patient populations, e.g., patients with obesity (27, 28) or those affiliated to the “lesbian, gay, bisexual, transgender, queer +” (LGBTQ+) community (29, 30).

Analysing demographic factors in our sample, we found that women tended to regard sex workers as more victimized than men. This is in line with a study which was conducted in undergraduate psychology students (9). The study found that women were more likely than men to disagree with decriminalization and legalization and that women were more likely to view sex work as reflecting exploitation and subordination. At the same time, the study found no relation between the view of sex work as reflecting exploitation and subordination and a profeminist mindset (9). Hence, it is likely that other factors explain these gender differences. It may be that females are more empathic than male physicians (31). Another reason may be that women are more likely than men to have already experienced discrimination themselves (32). Both reasons may prompt women to sympathize more with sex workers than men.

Moreover, in the current study, older participants tended to rate sex work as less of a choice and sex workers as more victimized than younger participants. This conforms with a study from India which found less stigmatized attitudes towards sex work and sex workers in younger compared to older adults (33). A possible explanation might be that younger participants tend to be more liberal than older ones in their opinions (34).

Another study examined nursing students’ knowledge and attitude towards sex workers in Hong Kong. The study found that the attitude towards sex workers and the agreement with human rights were significantly associated with the willingness to care for sex workers. However, the students had little knowledge of sex workers and fittingly final-year students (who were assumed to have more knowledge) had more positive attitudes towards sex workers than first-year students (10). This might deliver a possible explanation for the results of the current study: Healthcare professionals’ attitudes towards sex work and workers might be close to that of the general population because they do not have substantially more knowledge about sex workers. Future studies will need to focus on the question whether healthcare training needs to implement education on the specific occupational health risks and needs of sex workers and possibly other marginal societal groups. This is of crucial importance since other studies have shown that stigma-related barriers hinder healthcare utilization of sex workers (35). Whether more information alone would suffice, however, is questionable. Indeed, factual information is often insufficient to change stereotypes (36). Additionally, stereotyping often serves an (albeit subconscious) purpose and can be seen as motivated reasoning: For example, it might protect a person’s general view of the world (e.g., the “just-world belief” (37)) or might serve as a way to stabilize one’s self-esteem (38). Thus, providing factual information can only be considered as a potential first step.

Remarkably, more than 60% of our participants stated to treat none or less than ten sex workers per year. In 2021, 23,700 sex workers were officially registered in Germany as compared to 40,400 pre-pandemic. The estimated number of unreported cases is up to ten times higher (19). Thus, we assume that healthcare professionals often simply did not know they were treating a sex worker. Whether the patients’ profession was not a subject during medical history taking or nescience was caused by non-disclosure of the sex worker due to anticipated stigmata remains elusive. However, knowledge of a sex worker’s profession is of particular interest since sex workers have a higher risk for numerous health conditions such as human papilloma virus (HPV)- infections (39), related cancers, and/or other sexually transmitted diseases (STI), and are likely to be underdiagnosed and -treated (40). Although no modified screening procedures are established for sex workers, individualized handling for screening and eventually vaccination strategies are desirable (41). Thus, the knowledge on patients’ profession and its specific risk factors adds another layer to personalized preventive measures. However, the flipside could be that disclosing one’s profession might lead to more overt discrimination: Three participants of our study stated that they would refuse to treat sex workers, and another four stated they would do so under certain circumstances. Although these extreme statements were very rare, they do illustrate how dramatic stigmatization of sex workers might be in the healthcare system.

Interestingly, participants estimated a surprisingly high prevalence for somatic and mental disorders in sex workers. Although the exact prevalence in relation to the professional context (and thus, sex work) is not captured within the existing epidemiological registries in Germany and remains therefore an estimate itself, we expect the estimates being highly overrated. For example, a median prevalence of 20.7% for HIV seems far too high given the high frequency of obligatory healthcare check-ups in sex workers. This is supported by the fact that a prevalence of 0.2% for HIV among sex workers in Germany in 2010 was indicated (22), although this prevalence may not have captured illegal sex workers. In addition, small data sets are published for mental disorders among sex workers in Switzerland: Rössler et al. (21) interviewed 193 sex workers in and around Zurich and found a one-year prevalence of 24% for major depression, 34% for anxiety disorder, and 13% for post-traumatic stress disorder. Thus, healthcare professionals should be careful not to overestimate sex worker’s health risks. Our data are in line with previous views from sex workers themselves who reported that some healthcare professionals immediately assume they must suffer from an STI, are traumatized, or regard their work as the sole cause of any mental health issues, ignoring both the patient’s free will and true motivation (42, 43). In addition, sex workers and their clients are legally bound by German law to practice adequate prevention of STIs by consistent use of condoms. Given these results, it seems likely that these wrong assumptions might guide against evidence-based treatment.

Contrary to our hypothesis, more frequent professional contact with sex workers was not clearly correlated to participants’ views of sex workers: Across all frequencies of contact, the evaluation of sex workers and sex work as morally deviant was relatively constant. Only the view of sex work as choice differed, and those with more contact rated sex work as more of a choice. Interestingly, however, this did not extend to the evaluation of sex workers, who were not seen as more choosing/less victimized. As of yet, the reasons for this are unclear. One possibility would be that participants’ evaluation of sex workers as victims vs. choosing agents is relatively stable, and therefore does not change by frequent contacts (unlike factually incorrect stereotypes that would change). Interestingly, healthcare professionals’ estimates of the prevalence of various disorders were not only strikingly incorrect at times, but they were also influenced by participants’ attitudes towards sex workers: If sex workers were seen as more of a victim, they were attributed a higher prevalence, particularly of mental disorders. This indicates that healthcare professionals might be influenced by prejudices rather than by objective facts they should have acquired during their professional education. Alternatively, there might be a knowledge gap concerning sex workers during training of healthcare professionals which might need improvement. In any case, this finding indicates that healthcare professionals might rely on their gut feeling rather than on profound knowledge when estimating medical risks for sex workers, with potentially detrimental effects.

While our study provides valuable first information, it should be noted that it represents data from a convenience sample. Additionally, while being a sufficiently large sample, it is relatively small compared to the study population: There are about 420,000 physicians in Germany (44), about 50,000 psychotherapists (45), about 485,000 nurses in hospitals and almost a million further nurses in ambulatory settings or care homes (46). Hence, the study sample is not representative for the total group of healthcare professionals. The demographic data of the respondents were skewed towards younger age and female gender. Moreover, the majority of respondents worked in a hospital and in cities of more than 100,000 inhabitants. Also, the group of medical students was overrepresented compared to other professional groups. Attitudes towards sex work and sex workers might therefore differ in a more representative group of healthcare personnel and possibly in specific subgroups. Similarly, the view of sex work and sex workers is influenced by cultural and regional specifics. For example, sex work is legal in Germany, and our data might therefore not generalize to other European countries (e.g., France). Future studies should try to examine these questions in a more representative sample. Moreover, the results from our study do not allow any casual inference. It can only be speculated that negative attitudes towards sex work and sex workers may contribute to a poorer medical treatment. Future prospective trials are needed to address this hypothesis.

In conclusion, our data provide first evidence that healthcare professionals’ attitudes towards sex work and sex workers are similar to that of the general population, and that these are at least partly influenced by sociodemographic factors. Our data indicate that many healthcare professionals are uncertain how many sex workers they treat annually. It remains, however, unanswered if the sex worker does not disclose his/her profession to avoid anticipated discrimination or if the profession was not a subject of the medical history. Crucially, participants’ attitudes influenced their medical evaluation, indicating that more education about specific health risks of sex workers might be necessary to provide stigmatization-free healthcare. If healthcare professionals create environments in which sex workers are willing to disclose their profession, and healthcare institutions disseminate more information about specific health risks, this might enable better and more personalized medical care.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by IRB, Medical Faculty of the University Duisburg-Essen, Germany, ethics vote no.: 22-10678-BO. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

BL, AT, SR, and NN: conceptualization, formal analysis, funding acquisition, methodology, project administration, visualization, writing – original draft, and writing – review and editing. RV: data curation, methodology, and project administration. All authors contributed to the article and approved the submitted version.

This study was supported by the Mercur Research Center Ruhr (Essen, Germany) as part of the “Global Young Faculty VII” program. The funder of the study had no role in study design, data collection, analysis, and interpretation, writing of the report, or in the decision to submit the paper for publication. NN and AT held a position that was funded in part by the German Research Foundation (DFG) and the University Medicine Essen Clinician Scientist Academy (UMEA; grant no. FU356/12-2). SR was funded by the DFG (grant no. RE4543/1-1).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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