Crossroads of choice: a qualitative study of the factors influencing decisions to transition from sex work among women engaged in sex work in Southern Uganda

Abstract

Background

Women engaged in commercial sex work (WESW) are exposed to behavioral, biological, and structural factors that exacerbate their risk of HIV infection and other sexually transmitted infections. While commercial sex work may appear voluntary, WESW are more likely to be constrained to selling sex due to limited viable alternatives. To effectively support this vulnerable group of women, it is critical to understand factors that facilitate and impede their decisions to transition from sex work into other careers or jobs. The current study explored women’s decision to transition from sex work into other careers or jobs.

Methods

Face-to-face semi-structured in-depth interviews were conducted with 53 WESW aged 20–47 enrolled within the larger Kyaterekera study, a randomized clinical trial (N = 542) implemented in 19 geographical hotspots in the Southern region of Uganda. Participants were selected based on their level of intervention attendance (high/medium/low attendance) during the 12-month follow-up (Time 2). The interviews were conducted in Luganda the widely spoken language in the study area to explore the factors influencing women’s decisions to transition from sex work to other jobs or careers. The main interview question used for this study was, “What are some of the factors that may influence whether you would transition from sex work to other jobs or vocations?” All interviews were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis in Dedoose software was used to analyze the data.

Results

Participants reported three primary types of decisions, including considering leaving sex work, deciding to leave, and staying in sex work. The emerging themes from the interviews were categorized into individual and structural level facilitators and barriers to transitioning out of sex work. Individual-level factors included issues of stigma, discrimination, and aging as factors that facilitated women’s decision to leave sex work. At the interpersonal level, physical and sexual violence was noted as a reason to leave sex work. At the structural level, stigma and discrimination (from community members) were identified as facilitators to leaving sex work. Income-related factors were identified mainly as barriers to leaving sex work.

Conclusion

Our study highlights the complex decision-making processes among WESW as they navigate transitions to alternative jobs or careers. By advocating for multifaceted interventions and policies tailored to the diverse challenges faced by WESW, our study contributes to a more informed approach to supporting their transition out of sex work.

Introduction and background

The health risks and social stigma associated with commercial sex work remain a global public health concern in developed and developing countries [1]. Due to the nature of their work, Women engaged in commercial sex work (WESW) experience behavioral (e.g., inconsistent condom use, multiple and concurrent sexual partners, and alcohol and substance use) [2, 3], biological (e.g., high prevalence of sexually transmitted infections) [4, 5], and structural-level challenges (e.g., poverty, stigma and discrimination, gender inequality, physical and sexual violence) [6] that exacerbate their risk of HIV infection and other sexually transmitted infections (STIs).

Commercial sex work encompasses a range of activities that involve providing sexual services in exchange for money or goods. These activities include street-based sex work, escort services, brothel-based sex work, online or virtual sex work, and participation in adult entertainment industries (e.g., pornography) [7]. Poverty and lack of resources have been highlighted as the major drivers of sex work [8,9,10]. However, there are several other factors, such as a history of childhood physical and sexual abuse, neglect, drug addiction, and domestic violence. Despite the negative outcomes, such as the mental and physical health risks associated with sex work [12,13,14,14], once women get involved, it becomes rather challenging to exit sex work [15, 16]. As WESW continue to trade sex, they may be exposed to other problems like interpersonal violence, economic abuse, drug addiction, stigma and discrimination, arrest from law enforcement bodies, and mental health problems such as depression, stress, and anxiety [5, 17].

While commercial sex work may appear voluntary as a chosen source of income, WESW are more likely to be constrained to selling sex due to limited viable alternatives [18]. The topic of individuals transitioning out of sex work has gained significant attention within academic circles, with an expanding body of literature dedicated to exploring this complex process [19]. For instance, a study in the US found that race (being black) and age (entering sex work as a minor) were significant barriers to leaving sex work [20]. Another study in India identified key factors that would help women to exit sex work and these included support from social services agencies, positive relationships, employment opportunities, and better economic conditions [21]. The study highlighted that 70% of the women who participated in the study and had exited sex work emphasized the role of social welfare agencies in facilitating change towards their exit.

Several qualitative studies have also examined the experiences, challenges, and successes of women that are involved in exiting sex work [5, 23,24,24]. For instance, a qualitative study with 18 female sex workers in Ethiopia looked at the intentions, barriers, and opportunities to exit commercial sex work [5]. Results from this study indicated that women engaged in commercial sex work primarily as a means of survival. Moreover, limited access to viable financial alternatives created significant challenges for these women to exit commercial sex work. Similar results were reported in a study with 13 women engaged in street-based sex work in Ethiopia [25]. The study found that formal support services, support from family, spirituality, and saving money were factors that led to successful exit from street-based sex work. However, structural problems, drug addiction, and societal attitudes were identified as factors that led to re-entry into sex work.

Another study in Rwanda explored women’s experiences of joining and leaving sex work among 70 female sex workers [26]. Results showed that motivations to leave sex work included encountering a distressing incident, succumbing to peer pressure, and concerns about dependent children. A study that explored the challenges faced by women while attempting to exit “street-based” sex trade in South Africa highlighted the individual (trauma, physical health, fear of shame), relational factors (lack of social support from family and the community, family obligations), and structural factors (economic necessity, lack of alternative employment) as some of the major barriers to exit sex work [27].

In Uganda, the focus of this study, sex work continues to be illegal and highly stigmatized [28], compromising WESW’s ability to have access to resources they may need to successfully navigate the challenges associated with commercial sex work, including exiting sex work. Existing studies among WESW in Uganda primarily focus on HIV and STI prevalence and prevention, risk behaviors among this population, risk factors associated with sex work, and reasons for entry into sex work [6, 29, 30]. To our knowledge, no studies have examined the processes and factors related to sex work exit. Hence, this qualitative study serves to fill the gap in the literature and to inform research and practice on the relevant interventions and programs that can be designed to help vulnerable women successfully transition out of sex work.

Theoretical framework

This study is guided by Fuchs Ebaugh’s Role Exit Theory [31]. This theory explains how individuals separate themselves or exit from a particular role or social identity, such as exiting prostitution, conviction, or alcoholism [31]. The theory suggests that leaving a role happens gradually through several stages. It starts with ‘First Doubts,’ where individuals feel increasingly unsatisfied with their current situation, often because it no longer reflects their values. Next is ‘Seeking Alternatives,’ where they look for other roles that might better meet their needs. The ‘Turning Point’ comes when something significant prompts the decision to leave for good. The final stage is the ‘Creation of a New Identity,’ where individuals adjust to their new roles, building new relationships and reshaping their self-image. This process can be tough and stressful, as it often involves overcoming objections from friends and the community while transitioning away from a well-known identity. Moreover, individuals may experience different levels of support and resources during the exit process, which in turn can affect their ability to successfully transition into a new role. Månsson and Hedin [32] highlight that for someone to leave a role like sex work and tap into their creative potential, they need reliable social support, resources, and supportive institutions around them.

In this study, we utilized the Role Exit theory to examine the multilevel factors influencing the decisions of WESW as they consider transitioning out of sex work to alternative employment or vocations. Our results mapped onto individual, interpersonal, and structural level factors. This theory provides insights into the complexity of personal and external influences on their decisions. WESW often face considerable challenges including the psychological, financial, and social consequences of their potential choices. Factors such as feedback from others, a desire for autonomy, job fatigue, and persistent feelings of shame and stigma significantly affect their decision-making process [26, 27]. Thus, interventions aimed at supporting WESW in transitioning out of sex work must be thoughtfully designed to address the complex dynamics of role exit, acknowledging both the barriers and facilitators inherent in this life-changing decision.

Methods

Overall study design

This qualitative study is a component of a randomized clinical trial funded by the National Institute of Mental Health (R01MH116768). The study was designed to evaluate the effectiveness of a combination intervention that integrates microfinance components into traditional HIV risk reduction (HIVRR) strategies in reducing new cases of STIs among 542 WESW across 19 geographical hotspots in the Greater Masaka Region (Ssewamala et al., 2019). Eligibility criteria for WESW to participate in the study included: (1) being 18 years or older; (2) reporting engagement in unsafe transactional sex (defined as a sex act in exchange for pay) in the past 30 days; and (3) reporting involvement in one or more episodes of unprotected sex in the past 30 days [33].

The study employed an embedded experimental mixed methods design [34], collecting qualitative data across the study arms at three time points: at 6-month (Time 1), 12-month (Time 2), and 24-month (Time 3) [30].

Ethical considerations

All study procedures were approved by the Washington University in St. Louis Institutional Review Board (#201811106), Columbia University Institutional Review Board (IRB-AAAR9804), and the in-country Institutional Review Boards in Uganda: Uganda Virus Research Institute (UVRI—GC/127/18/10/690), and the Uganda National Council of Science and Technology (UNCST—SS4828). Written consent was obtained from all WESW in the study. The study was also overseen by an in-country Data Safety and Monitoring Board [33]. Participants who tested positive for HIV during the study were referred to HIV clinics for antiretroviral therapy (ART) treatment and counseling.

Qualitative sample selection

A stratified purposive sampling strategy was used to represent the wide range of experiences. The qualitative sampling was based on participants’ attendance of intervention sessions, specifically HIV risk reduction (4 sessions) and financial literacy training (6 sessions) sessions (see the study protocol [33] for details on the study intervention). For each site (n = 19), one participant from the highest, mid (average), and lowest quartiles of the total number of attended sessions was selected (n = 57). For Time 2 qualitative data collection, semi-structured in-depth interviews were completed with 53 participants from 19 sites.

Data collection

Face-to-face semi-structured in-depth interviews were conducted with 53 WESW at 12-month (Time 2) follow-up. Time 2 interviews focused on participants’ living experiences, the difficulties they faced in their daily living situations, and their experiences with the intervention and its specific components. Additionally, participants were asked about their financial decision-making and its impact on several aspects of life such as parenting, becoming pregnant, engaging in protected and unprotected sex, and transitioning to different jobs or vocations, among others. The main interview question used for this study was, “What are some of the factors that may influence whether you would transition from sex work to other jobs or vocations?”

Interviews were conducted in Luganda, the local language widely used in the study region. The semi-structured interview guide was translated from Luganda to English and back- translated to Luganda by proficient team members. Interview questions were reviewed and revised by the study team, which included research assistants and co-investigators fluent in both languages to ensure that the questions were culturally and contextually appropriate. Interviews were conducted by male and female research assistants fluent in both Luganda and English and trained extensively by two authors with qualitative research expertise. The qualitative interviews were conducted in a private place with only the research assistant and the participant to ensure confidentiality and avoid interruptions. Interviews lasted between 88 and 268 min (average 140 min). All interviews were audiotaped with consent from the participants, and field notes were taken upon completion.

Data analysis

All interviews were transcribed and translated verbatim to English before exporting to Dedoose software to facilitate the data analysis process. We used thematic analysis with both deductive and inductive approaches to analyze the data [35, 36]. The data analysis revealed several subthemes related to the decisions of sex workers to consider leaving sex work, the decision-making process involved in leaving sex work, and the factors influencing their choices to remain in sex work. These decisions were influenced by a combination of individual, interpersonal, and structural factors. Interview transcripts were initially read multiple times and independently coded by two authors using sensitizing concepts informed by the existing literature as well as identifying emergent themes (open coding) [36, 37]. Broader themes were broken down into smaller, more specific units until no further subcategory was necessary. Initial codes were discussed during team meetings and reorganized when necessary to create a final codebook that was used to code all transcripts. The next phase of data analysis, conducted by two authors, compared and contrasted themes and categories to identify similarities, differences, and relationships among findings. Peer debriefing and audit trail were used to ensure rigor [38, 39]. Specifically, the codes and the findings were presented to the study team who were not involved in the data analysis to discuss the plausibility of themes and related findings [39].

Results

Participant demographics

Participants’ ages ranged between 20 and 47 years (mean age: 31.79) (Table 1). 58% (58%) of the participants were divorced, half of them (50%) belonged to the Catholic religion, and at least 38% had dropped out before completing primary school. The average household size was 3.07 (ranging from 1 to 8 members), with an average of 1.66 children under 18 years per household (ranging from 0 to 6 children). Participants’ monthly income ranged between 10,000 and 700,000 Ugandan shillings ($2.74 to $191.78 at a rate of $3,650). All participants were tested for HIV and other STIs and 64% of the women tested negative for HIV. Participants had spent at least six years in sex work with a mean age of twenty-five years at the time of starting sex work. Participants also reported to have had an average of 28 customers in the last 30 days. To ensure the privacy and confidentiality of participants, pseudonyms are utilized throughout.

Table 1 Participant demographic characteristics- Kyaterekera qualitative interviews- time 2 (N = 53)

Factors influencing women’s decisions to transition from sex work

Participants reported three main types of decisions regarding their transitioning from sex work: (1) Considering leaving sex work, (2) Leaving sex work, and (3) Staying in sex work. Among the three types of decisions made by WESW, a range of factors at the individual and structural levels were identified to have influenced the decisions taken. These factors were found to be relevant to all three types of decisions mentioned. Of the 53 women interviewed, 30 reported that they were considering leaving sex work, six stated that they had decided to leave sex work, and 17 reported that they had chosen to remain in sex work.

Individual-level factors

Irrespective of the specific decision made (considering leaving sex work, leaving sex work, or staying in sex work), the decisions of WESW to transition were influenced by a variety- of individual-level factors. We operationalized “individual-level factors” as those factors that pertain to the internalized experiences and characteristics of WESW themselves. WESW’s narratives focused on factors that included anticipated stigma and discrimination, and age.

Anticipated stigma and discrimination

Anticipated stigma and discrimination refer to the expectation or fear of experiencing negative treatment or judgment based on a stigmatized characteristic or status [40]. In the context of sex work, women expressed concerns about how society, family, and community members might react if their involvement in sex work were discovered. This fear of future judgment, although not always rooted in current experiences of direct discrimination, shaped their decision-making processes, and contributed to feelings of shame and anxiety.

Some participants discussed how the anticipated stigma impacted their self-esteem and social relationships, leading to feelings of devaluation. For example, Kateri (35 years old) and Fatumah (33 years old), who were considering leaving sex work, articulated their decision by expressing embarrassment over the nature of their job:

Kateri: I am deciding to do another job because this job is embarrassing.

Fatumah: Currently, I am considering transitioning to another job if I happen to get it because working as a Neko (sex worker) is perceived as evil.

Other women expressed how societal disrespect and mockery made them feel ashamed, further driving their desire to leave. Kirabo (27 years old) explained how this external disrespect led her to question her involvement in sex work, “They laugh at you, they disrespect you, and you start feeling ashamed of what you are doing.” This sentiment was echoed by Jessica (33 years old), who shared how sex work prevented her from being open with her friends, “What can make me decide to quit the Neko job is that it is not respectable, and you cannot tell your friends that “this is my job; I sell sex” you see?”

Even for those women who had chosen to stay in sex work, there was a recognition that the job was not something they felt proud of. Rebecca (33 years old), who had decided to stay, expressed that while she continued with sex work, she still felt stigmatized by society:

First of all, this isn’t a job that you can be proud of with other people apart from fellow Nekos. If you happen to get another job that can be presented to others, you can stop being a Neko and run the other job.

In some cases, the anticipated stigma extended to fears of how family members or community acquaintances might react if they discovered the participant’s involvement in sex work. This fear of judgment, though often hypothetical, had a profound influence on their desire to leave sex work. For instance, Helen (30 years old) who had decided to stay in sex work but was searching for alternative employment, highlighted her concerns about the potential for her family or community members to find out:

First of all, we have a bad image from the people who are not engaged in this work. My family members may get to know the type of work I do. Or one of the community members may come across us on the streets, and he sees me and goes back to gossip about me. That is why most of us wish to engage in this work for a short period as we look for other jobs.

In summary, the women’s fears of anticipated stigma and discrimination were central to their decisions about transitioning out of sex work. These fears, often rooted in potential, not actual experiences, created complex dynamics that deeply influenced their self-perception and decisions about their future livelihoods. The “breaking point” for many women contemplating leaving sex work was often tied to the potential discovery of their work by family members or community members rather than current, tangible experiences of stigma or discrimination.

Women’s age

Among those considering leaving sex work, age was mentioned, as a contributing factor. Although participants did not specify an exact age range they considered “old,” they emphasized that advancing in age influenced their decision-making, citing concerns about personal dignity and the nature of the work they could engage in as they aged. Participants also expressed that as they grew older (not mentioning the exact age they referred to), so did their children, this would potentially lead to feelings of shame. Furthermore, participants noted that aging could negatively affect their marketability, resulting in reduced payments from clients. Diana (33 years old) who was considering leaving sex work mentioned:

Things like age as each year that passes, I grow older, which comes about with personal dignity. When children grow up and realize that [you are selling sex], it brings about shame. So, age might bring about quitting the job. And another thing, customers might reduce what they pay.

Angela (29 years old) was also concerned about how age, specifically old age, affected the demand for WESW. This influenced her decision to consider leaving sex work, “Even the Nekos have their market, as you age, the demand reduces. So, that can also influence me to transition to other jobs.” Mariam (46 years old) pointed out that as a WESW, she contemplated her future and knew that one day she would grow old and must leave sex work, “As you are silently seated, you think of the fact that you are growing up, and then make a decision to leave some jobs and transition to others.”

Sarah (35 years old) who had decided to leave sex work, mentioned that she knew she was getting older, and so did her children. She stated that her children may find out the type of work she was doing, and she decided to quit before that time came, “Each and every day, I am getting older and also the children I am taking care of are also growing up.”

Interpersonal level factors

The interpersonal level factors refer to the qualities or nature of one’s social experiences. In this context, interpersonal factors focused on the WESW-customer relations primarily characterized by violence.

Physical and sexual violence

WESW experience various forms of physical violence from their customers, ranging from instances of strangulation to attempted murder. Additionally, some WESW experience sexual violence in the form of attempted rape perpetrated by customers. These risks significantly contribute to negative health consequences for WESW, such as exposure to STIs and HIV, unintended pregnancies, abortion, as well as emotional and mental health issues. These risks also serve as major factors compelling WESW to turn to alcohol and other drugs as coping mechanisms while engaged in sex work.

Regardless of the decision taken, WESW consistently reported instances of physical and sexual violence, which served as both significant barriers and motivating factors for their transition out of sex work. For example, WESW who were considering leaving sex work reported incidents of rape and torture from customers, including being strangled. Similar issues were raised by WESW who decided to leave sex work. Some of these women had also experienced theft from customers, non-payment by customers, and physical fights initiated by customers. Even among WESW who had chosen to stay in sex work, similar experiences were acknowledged and recounted.

Anitah (32 years old), who was considering leaving sex work, reported an incident where a customer attempted to rape her. Such an incident left her with emotional and physical pain, “A customer has attempted to rape me, and, in this attempt, I was torn. So, when I think about that situation, I wish I could have another job to do other than that [sex work].”

Multiple cases of customer-inflicted torture were reported by the women, involving distressing acts such as strangulation. Four women who were considering leaving sex work shared similar experiences. Theresa (36 years old) disclosed instances of torture and non-payment by customers despite engaging in sexual activities with them. Theresa also highlighted incidents where customers refused to use condoms:

Neko business involves torture, sometimes, a customer refuses to pay even after having sex with you, yet he has affected your life. Other times he refuses to use condoms even when you ask him to use them.

Ruth (32 years old) reported about experiences of being strangled inflicted by customers, “One major factor that could make me leave sex work is that it has a lot of problems, many women lose their lives to being strangled and killed. Beatrice (26 years old) and Lucy (40 years old) shared similar sentiments:

Beatrice: The problem in it [sex work] is getting a customer after agreeing when you get there…[he] wants to use you without giving you any coin, sometimes in such a bad situation and after using you, then wants to kill you.

Lucy: Being a Neko, we encounter many challenges like you can be killed. This can be done by the customers or someone else can be sent by another person to kill you.

Women who were considering leaving sex work were motivated by the physical and sexual violence perpetrated by their customers. Women who chose to leave sex work shared comparable experiences to those who were considering leaving sex work. These experiences included instances of theft from customers, non-payment for services rendered, attempted rape, and physical fights initiated by customers. The cumulative impact of these risks played a significant role in their decision to transition from sex work.

Regina (34 years old) reported about how some customers refused to use condoms in addition to stealing from them:

The way we are treated… You can bring in a man, but he does not want to use a condom. You take him into a room, and he causes harm to you, he steals your money. There are many things associated with prostitution.

Nadia (41 years old), who decided to leave sex work, shared her personal experience, which likely played a role in shaping her choice to leave sex work, “There are many reasons I would leave that job; you may be coming from there, and they rape you.” Ritah (37 years old), who also had decided to leave sex work, narrates similar experiences of physical violence from customers who, at the same time, did not want to pay:

We were always facing challenges previously. You could get a man when he is drunk, and he would want to take you [have sex with you] for free, sometimes, he would use you and not pay you or he would fight you after using you. So, I decided to find ways of leaving the job.

Structural level factors

We operationalized “structural level factors” to encompass broader societal, economic, and environmental influences that shape the context in which sex work occurs. WESW’s narratives focused on factors that include interpersonal stigma and discrimination from community members and income-related factors.

Interpersonal stigma and discrimination

In addition to the anticipated stigma and discrimination, WESW described experiencing interpersonal stigma and discrimination from the communities in which they lived. They recounted instances where they were excluded from community gatherings and faced disrespect, even from those of lower social status than themselves. In this context, “lower social status” refers to individuals who, despite their financial or social struggles, still look down on WESW, perhaps due to cultural or societal norms. This reflected a complex social hierarchy that was often intertwined with cultural and moral judgments. For example, Cecilia (25 years old) who was considering leaving sex work, shared, “You might get despised by a person who shouldn’t have despised you, but because you are a Neko…”. Grace (34 years old), another woman considering leaving sex work, highlighted the emotional impact of this stigma, stating, “This job is embarrassing and makes you disrespected in the community and that is why most of us feel shy and act as if we are mentally ill. You feel frustrated.” Matilda (25 years old) echoed similar feelings of dehumanization, explaining, “People talking about you and treating you like you are not human, that you are just Neko. That’s why I work hard so that I can quit that job.”

Regina (34 years old) who had decided to leave sex work expressed feeling marginalized within her community, citing instances where her legitimate issues, such as falling ill, were disregarded, and she was denied fair consideration and treatment. This dehumanizing treatment played a pivotal role in her decision to leave sex work.

A Neko does not bring up suggestions. She cannot sit in any meeting. People would be like “what is that Neko suggesting?” Even when you have a problem, you have been attacked by sickness and fallen, they will say that “Neko was drunk” even [though it was never the case]…”.

Income-related factors

WESW expressed a range of reasons for engaging in sex work, often rooted in financial constraints but also influenced by broader challenges, including raising capital, limited employment opportunities, family responsibilities, and aspirations for a more stable future. For example, Afiya (27 years old) shared that:

If I get capital, I will start up a business where I can earn income so that I can take care of my children and leave sex work. For sure, this is not the kind of job I am proud of or what I can share with my friends.

Similarly, women who were still considering leaving sex work described financial constraints as a major barrier to transitioning. Some women expressed the need for start-up capital to start or expand businesses that could provide them with a sustainable income. For instance, Betty (26 years old) and Josephine (28 years old) noted that if they obtained enough capital, they would leave sex work. Betty stated, “Getting capital, which capital is enough for me, or when my business expands, there I can quit sex work and concentrate on my business.” Josephine shared a similar sentiment, “I can leave sex work if I get enough capital, start up my business, and get enough money to meet my needs.”

In addition, some women who had decided to stay in sex work indicated that they would transition if they found a viable alternative source of income or employment. Lydia (29 years old) and Winnie (35 years old) both mentioned that although they were staying in sex work, they would leave if they secured another job. Lydia said, “If I get another job that I earn income from then I drop the sex work job.” Winnie echoed this by stating, “What may cause me to transition is when I get a job.”

Other women were making plans for the future while remaining in sex work. Amina (29 years old) explained that although she currently intended to stay in sex work, her long-term plan was to transition once she felt secure. She shared, “I am preparing myself and I am completing building my house such that by the time I quit, I am not a tenant, and also when my children are educated.”

While financial constraints were prevalent across women’s experiences, some, like Nadia (41 years old), ultimately decided to leave sex work due to low financial returns and the toll on her health. Nadia explained, “I have not gained much from my time as a Neko; when you get money, it vanishes when you have also contracted diseases.”

In conclusion, the decision-making process for WESW regarding their transition out of sex work is multifaceted, shaped by a complex interplay of individual and structural factors. At the individual level, anticipated stigma and discrimination, along with challenges related to aging, often prompted women to consider or take steps toward leaving the industry. The stigma impacts not only their self-esteem and mental well-being but also their family relationships, particularly their concerns about the future of their children.

Moreover, at the structural level, pervasive issues such as physical or sexual violence, interpersonal stigma and discrimination, and economic instability profoundly affect WESW’s transition out of sex work. These structural challenges create a hostile environment that exacerbates vulnerabilities and limits women’s options for alternative livelihoods. Addressing both individual and structural barriers is essential for developing comprehensive interventions that support WESW in their efforts to transition out of sex work.

Discussion

Guided by Role Exit Theory, this study explored the decision-making process related to transitioning out of sex work into other jobs among WESW in Uganda. The sampling strategy, which included participants with varying levels of intervention attendance, allowed for a nuanced exploration of the decision-making process, capturing diverse experiences across diverse levels of engagement. We identified three primary types of decisions that WESW took in their transitioning journey from sex work. These include WESW who were still considering leaving sex work, reflecting the ‘First Doubts’ stage of the theory, those who had decisively chosen to leave, aligning with the ‘Turning Point’, and those who decided to stay in sex work, which provides insights into the barriers faced during the ‘Seeking Alternatives’ stage. According to the theory, the first stage, ‘First Doubts,’ was evident in our findings, where a considerable number of WESW were still considering leaving sex work. These initial doubts were primarily driven by anticipated stigma, discrimination, and age factors, highlighting the internal conflict and dissatisfaction that preceded the decision to exit. In the ‘Seeking Alternatives’ stage, those WESW who had decided to leave sex work began exploring other employment opportunities, reflecting an active search for viable alternatives to their current roles. This aligns with our observation of individual-level drivers pushing toward transition. However, interpersonal and structural barriers such as physical and sexual violence, interpersonal stigma and discrimination, and income-related factors were evident, thus complicating the transition process by limiting the feasibility of alternative options.

The concept of stigma and discrimination, as explored in this study at both the individual and structural levels, emphasizes the psychological burden faced by WESW. The expectation of prejudice and judgment, irrespective of direct or indirect experiences of stigma and discrimination, can catalyze a cycle of self-stigmatization. This internalization of societal values manifests as profound emotional distress, potentially impacting the mental health of WESW. Consistent with previous studies, WESW continue to face different forms of stigma and discrimination and are commonly seen as deviant from the social norms of society [41]. WESW face stigma and discrimination from family members and the communities they live in [44,45,44]. This greatly impacts their mental health [45], family relationships [5, 40, 46], participation in communities, and access and utilization of health services such as HIV testing and treatment [10]. Lack of utilization and access to health services in turn exacerbates WESW’s burden of HIV, risk of HIV transmission, and poor treatment outcomes [47, 48].

Age was another critical factor with profound implications for their personal and professional lives. Our study revealed that advancing in age (for sex workers) is not merely a chronological marker but a critical point that intersects with social norms, economic realities, and personal dignity, influencing the decision to transition out of sex work. According to the experiences shared by WESW, advancing in age affected how these women perceive their future within the industry and their potential for employment outside of it. WESW’s experiences highlighted that older sex workers may experience a decline in demand for their services due to societal ageist attitudes, which can impact their earning potential and economic stability. This economic pressure, coupled with the desire for personal dignity and societal respect, can influence WESW’s decision to transition out of sex work. Age can also intersect with social norms that stigmatize and marginalize WESW, especially as they get older making it challenging for older sex workers to integrate into other professions or social networks.

Our study findings also highlighted the intersection of physical and sexual violence with sex work which also raises profound questions about the safety and well-being of WESW. This study has illuminated the disturbing reality that such violence is not an anomaly but a pervasive risk that WESW encounter regularly. The implications of these experiences are multifaceted, affecting the physical and mental health and well-being of WESW [12], and influencing the critical decisions of whether to continue with or leave sex work. Similar to our study findings, instances of physical and sexual violence, including physical fights and rape, have been previously documented by WESW in a study conducted by Witte and colleagues [49] in Mongolia. Physical and sexual violence experienced by WESW contributes to a heightened risk of STIs and HIV, unintended pregnancies, and the necessity for abortions, which are significant health burdens [13, 49, 50]. Benoit and colleagues [41] highlighted that given the high frequency of sexual risk-taking behaviors among WESW, they have the highest HIV prevalence rates when compared to the general population globally and in Uganda as well [45, 51]. Moreover, the emotional trauma accompanying such violence can lead to long-term psychological distress, including post-traumatic stress disorder (PTSD), depression, and anxiety.

The recurrence of violence in the narratives of WESW, regardless of their future intentions within the industry, suggests that violence is a systemic issue rather than an isolated incident. It indicates a need for structural interventions, including legal reforms to protect the rights and safety of sex workers, and the establishment of support systems for victims of such violence. The coping mechanisms that WESW adopt, often involving the use of alcohol and other drugs [49, 52, 53], point to the inadequate support and resources available to them. These strategies, while providing temporary relief, may further compound their health risks and socioeconomic vulnerabilities [13, 14, 54, 55].

In addition, the decision to leave sex work, as influenced by experiences of violence, reflects a crucial survival strategy. It is a response not only to immediate harm but also to the anticipation of future risks. This anticipation of harm plays a critical role in decision-making processes and highlights the need for alternative employment opportunities that offer safety and dignity to WESW. The study findings call for a comprehensive approach to addressing violence against sex workers. This includes policy changes that decriminalize sex work and destigmatize those within the industry, community-led initiatives to provide support and advocacy, and healthcare services that are accessible and sensitive to the needs of WESW. Moreover, experiences shared by WESW in this study suggest that societal attitudes toward sex work contribute to a culture of impunity where violence against WESW is normalized as highlighted by Caldwell and de Wit [56]. This normalization of violence has deep societal implications, as it not only affects the individuals involved but also reflects and reinforces gendered power imbalances and societal perceptions of WESW.

In terms of income-related factors, this was a common factor influencing women’s decisions to transition from sex work. This factor was commonly mentioned by women who were considering leaving sex work and those who had decided to stay in sex work. The relationship between economic necessity and engagement in sex work is complex and multifaceted, reflecting the broader socioeconomic conditions that often limit the choices available to WESW. The necessity for financial resources, articulated through the need for start-up capital and financial stability, highlights a significant barrier to exiting sex work. WESW’s aspirations for financial independence through entrepreneurship or stable employment are often hindered by economic constraints faced by women in general. Research has emphasized that financial stability, achieved through a supportive relationship, access to bank loans, financial aid for starting a business, or assistance from friends or relatives, is a critical factor in facilitating the transition out of sex work [5, 57]. This underscores the critical role of economic empowerment interventions [33] and the availability of capital as determinants in the potential transition away from sex work.

The drive for financial stability is not only motivated by the individual WESW’s needs but also by the responsibilities they hold, such as providing for children and securing housing or shelter. This dual pressure of personal and familial financial obligations indicates that economic incentives are deeply intertwined with social and familial roles, reinforcing the centrality of income in WESW’s decision-making process. However, planning for the future, such as starting a business or expanding existing ventures, illustrates a forward-looking strategy among WESW. This forward-planning is, however, contingent upon access to financial resources, which can be a significant barrier for many WESW. The lack of access to capital and financial services for WESW reflects broader structural inequities that must be addressed to facilitate successful transitions out of sex work.

Recognizing the dynamic interplay between individual agency and structural constraints is crucial for designing effective policies and interventions aimed at supporting WESW in their transition out of sex work. Efforts to mitigate the impact of stigma and discrimination should be accompanied by initiatives addressing the root causes of violence and economic marginalization within the sex work industry and women in general.

Thus, supporting women transitioning from sex work, interventions and policies must adopt a multifaceted approach. This includes advocating for legal reforms to decriminalize sex work and destigmatize those involved, as well as enabling protection from all forms of violence [58]. Decriminalization of sex work is foundational for enabling safer working conditions and better health outcomes for WESW [59]. In addition, there should be accessible healthcare services sensitive to sex workers’ needs, along with safety measures and support systems, which are crucial to address the physical and mental health consequences of violence and stigma experienced by WESW [58]. Further still, addressing societal attitudes through awareness campaigns and integrating sex workers into broader social networks fosters a supportive environment for transitioning into other professions.

Our findings emphasize the critical need for economic empowerment interventions tailored for WESW, including savings-led microfinance, vocational and skills training, and entrepreneurship programs. These interventions may provide essential resources to help WESW overcome financial barriers to exiting sex work, supporting sustainable transitions into alternative professions. The participants in our study were enrolled in the Kyaterekera intervention, an economic empowerment program that included financial literacy training and access to a matched savings individual development account (IDA) [33]. This intervention aimed to build financial resilience by teaching essential skills in saving, budgeting (including household budget development), and debt management, while offering a safer and sustainable income alternative to sex work, a highly stigmatized and risky form of earning [33]. However, it is important to note that the data used in our analysis was collected at Time 2 follow-up interviews when the intervention was still ongoing. As a result, some anticipated outcomes—particularly regarding participants’ financial preparedness and their transition into alternative livelihoods—may not yet be fully realized.

Economic empowerment interventions specifically those tailored to savings-led microfinance can reduce the stigma and discrimination faced by WESW by creating new identities as entrepreneurs or skilled workers [49, 50, 60], thereby integrating them into more socially accepted roles. With enhanced financial resources, WESW are better positioned to leave environments where they are vulnerable to violence, securing safer living conditions for themselves and their children. This shift can improve their agency, sense of dignity, and opportunities for personal growth and development.

In the context of the Uganda Government Vision of 2040 which focuses on the financial inclusion of vulnerable groups, including WESW [33], economic empowerment interventions are aligned with broader development goals. Ensuring that WESW are included in financial growth strategies not only helps them individually but also contributes to the economic and social development of the nation as a whole. These structural interventions thus act as a bridge, providing the necessary support and resources at the macro level to address and mitigate the challenges faced at the micro or individual level.

It is important to acknowledge that other factors such as stigma, discrimination, aging, and experiences of violence are deeply interwoven with economic stability and opportunity. Without financial security, the ability of WESW to leave sex work is significantly constrained, as the risk of poverty and inability to provide for themselves and their families can perpetuate their involvement in sex work despite the presence of these barriers and motivators. This comprehensive approach can enable WESW to make a sustainable transition out of sex work and into alternative professions where they can thrive.

Strengths and limitations

Our study highlights significant findings about the complexity and multifaceted decision-making among WESW to transition from sex work. The study’s emphasis on individual and structural factors provides a comprehensive understanding of the complexities involved in the transition from sex work to other vocations. By focusing on stigma and discrimination, age, physical and sexual violence, and income as key influences in the decision-making process, the research offers valuable insights into the psychosocial and economic dynamics that drive WESW’s decisions. The consideration of stigma and discrimination, particularly, amplifies the psychological burden and societal challenges faced by WESW, highlighting an area that is often overlooked in research. The inclusion of age as a factor sheds light on the intersectionality of sex work with societal norms and economic realities, offering a nuanced perspective on the life course of WESW. The study’s findings on violence provide critical data on the risks associated with sex work, reinforcing the need for structural interventions and support systems that target WESW. The emphasis on economic factors, particularly the necessity for financial resources and the barriers to financial independence, aligns with broader socio-economic challenges that women face in general in developing countries.

A key strength of this study is the stratified sampling strategy, which included women with various levels of intervention attendance– ranging from minimal to full participation. This approach allowed for a richer understanding of the diverse factors influencing WESW’s decisions to transition out of sex work. By capturing the perspectives of women at varying levels of engagement, we were able to identify patterns in decision-making that might otherwise have been overlooked, including nuanced insights into barriers and facilitators to transition. These findings underscore the importance of incorporating diverse experiences to inform interventions that are both inclusive and equitable.

Despite its strengths, the study also has some limitations. One major limitation of this study is that the analysis and data collection were not originally targeted explicitly on the issue of women’s transition from sex work. Thus, future research should be done with more comprehensive questions on women’s decisions to transition from sex work. This study analyzed data from one time point. Longitudinal data should be analyzed to examine WESW’s trajectories with transitioning from sex work. Although the research provides a thorough analysis of the various influences on WESW’s decisions, it may not fully capture the diversity of experiences among sex workers in different regions or with different socio-economic backgrounds.

Conclusion

Our study’s findings highlight how challenges like stigma, discrimination, aging, and violence are intricately linked with the struggle for economic autonomy for WESW. These adversities not only precipitate the doubt that WESW must exit sex work but also underscore the urgency for WESW to seek alternative livelihoods that offer both financial stability and freedom from the current occupational identity.

The quest for alternatives, as posited by the role exit theory and observed in our findings, is not a sole endeavor for WESW but one that necessitates robust support systems and resources. The exit from sex work, laden with potential psychological, financial, and social consequences, is navigated with varying levels of support, reflecting the theory’s recognition of differential access to resources during role transitions. Our conclusions advocate for multifaceted interventions and policies that address the different challenges that WESW face as they consider transitioning from sex work.