"They look you up and down like you are nothing": A qualitative exploration of sex workers' health needs and interactions with UK healthcare services.

Background: Sex workers are frequently regarded by health services as a homogenous group whose health needs are related exclusively to the services they provide. Little research has explored sex workers' health needs from their own perspectives. Aim: To understand their healthcare needs from their experiences and perspectives. Design: We undertook a four phase multi-method study to assess the health needs of sex workers in Birmingham, UK. This article reports the findings from qualitative interviews with sex workers (phase three). Settings: This study was conducted in the UK with sex workers living and/or working in Birmingham, UK. Participants: 20 sex workers (10 men, 6 women, 2 trans/non-binary, and 2 not disclosed), were interviewed who were over 18 (21-40yrs): offering paid for sexual services involving in-person interactions. Online only service providers were excluded. Participants were recruited via partner organisations, personal networks, and social media (X). Methods: We undertook semi-structured interviews which explored healthcare needs and access for sex workers. Interviews were audio-recorded. Audio files were transcribed, and clean transcripts imported into NVivo to support data analysis. Transcripts were thematically analysed and mapped deductively against the adapted Andersen Model of Healthcare Service Utilisation. Results: Themes interpreted from interview analysis related to healthcare need, enabling factors, service provision and barriers to access. A further category "In an Ideal World" was interpreted inductively reflecting gaps in current healthcare service provision and access. Themes included: fear of judgement and stigma; social taboos; feeling unheard and dismissed by services (missed opportunities for engagement); judgmental service provision; and availability of tailored services and appropriately trained staff. Conclusions: Many sex workers experiences were underpinned by frequent exposure to psychological and physical trauma and violence, either related to lifetime experiences, experiences as a sex worker, and through contact with healthcare or support services. The intersecting marginalised identities of many sex workers were also a feature of their trauma exposure and interactions with healthcare staff. Recommendations include creation of holistic services; training of non-judgemental staff with insight into the complexities of sex work and the intersections of the multiple marginalisations sex workers face; appropriate training for staff in statutory services, e.g., General Practitioner (GP) primary healthcare practices; trained points of contact who can advocate and educate within their services; availability of peer support; integrated service pathways incorporating 'fast track' referral systems between partner organisations.