The Mental Health of Women Sex Workers: Negotiating Multiple Pandemics

Background: The prevalence of mental illness in India has reached 15% in the general population, and factors undermining mental health pose significant challenges to the well-being of people, especially in poor communities. The situation is worsened by a severe shortage of mental health professionals, with only 0.3 psychiatrists and 0.07 psychologists per 100,000 people, compared to a global rate of 6.6 psychiatrists per 100,000. Access to mental health services is hindered by stigma, financial challenges, a lack of professionals, and limited awareness. The biomedical model of mental illness may not apply to the Indian context: with mental disorders usually being attributed to social and economic factors, a biomedical etiological model might exacerbate stigma, shame, and discrimination.

Sex workers carry a disproportionate burden of poor mental health outcomes due to the challenges posed by their work conditions that include factors such as increased criminalization, violence, or unsafe work settings, stigma, and marginalization. Moreover, sex workers are especially vulnerable to pandemics such as HIV and COVID-19. The latter has exacerbated economic insecurity, legal precarity, and violence. Few studies have examined the mental health of sex workers, or how the recent pandemic has affected them.

This research addresses the vacuum in the mental health literature by examining the factors shaping mental health among sex workers in Kolkata, India.

Methods: We conducted 30 semi-structured qualitative interviews of women sex workers in three red-light districts in and around Kolkata. We analyzed the data using a grounded theory approach with sensitizing concepts.

Results: We identified factors at three levels shaping mental health among participants: the societal (structural), organizational (meso), and individual levels. Mental well-being was undermined: 1) at the societal level, by sex work-related stigma braided with cultural tropes, lack of access to knowledge and services, poverty, and criminalization; 2) at the organizational level by disruptions in supportive sex work collectives triggered by: a) cessation of service provision due to crises like Covid-19 and typhoons, and b) power struggles in movement leadership that differentially affected sex workers based on their social locations; and 3) at the individual level, by past experiences of violence and trauma, and a constrained interpretive schema that forced sex workers to draw on normative notions of pathologization such as somatization and over-experiencing feelings of “tension”.

Conclusions and Implications: Amartya Sen’s framework of capabilities that emerged from his analysis of poor people’s communities in India was utilized as a culturally appropriate framework to interpret the results. We argue that capability-constraints at multiple levels shaped mental illness for sex workers, thereby also enunciating the pathways to a multilevel expansion of capabilities to improve mental health.