Vulnerable exposures and outcomes for children of female sex workers in low- and middle-income countries: application of the bioecological vulnerability framework.

INTRODUCTION: Children of female sex workers (CFSW) are exposed to unique bioecological vulnerabilities that negatively affect their developmental outcomes. We interviewed 1,280 female sex worker mothers (FSWM) in eight low- and middle-income countries (Angola, Brazil, South Africa, the Democratic Republic of Congo, India, Indonesia, Kenya, and Nigeria) between January 16 and October 1, 2019. This exploratory study focused on multilayered exposures from early childhood to adolescence, resulting in maldevelopment and other negative outcomes for CFSW, as reported by their mothers.

METHODS: We used Bronfenbrenner's revised Bioecological System Theory of Human Development as the analytical framework. The interview data included both numerical responses and brief textual answers. Quantitative information was summarized using prevalence estimates, while textual responses were inductively coded and grouped into major categories.

RESULTS: FSWM reported that outcomes varied across countries but reflected complex interactions within and between the micro-, meso-, exo-, and macro-systems described by the theoretical framework. Findings revealed that CFSW were exposed to suboptimal child-rearing environments and faced a high prevalence of adverse outcomes. A majority (61%; country range, 45-67%) of daughters entered sex work at an early age (mean age: 14 years; range, 13.5-18 years). Both sons and daughters experienced physical harm (72%; range, 21-85%) and sexual abuse (sons, 57%; daughters, 74%). Daughters were often introduced to sex work as a survival strategy. Reported outcomes also highlighted bioecological vulnerabilities that impeded sons' development, as well as protective environments that supported their healthy growth. These were categorized as follows: (1) vulnerabilities associated with high-risk living environments such as brothels, hotspots, and streets where they were exposed to sex work; (2) negative psychological, physical, and behavioral outcomes, including becoming criminals, victims, and perpetrators of abuse; and (3) protective environments of living away from the mother's work and finding informal work that may mitigate the harmful effects of bioecological vulnerable exposures.

DISCUSSION: The CFSW experienced significant threats to healthy development, contributing to adverse physical and psychological developmental outcomes. These findings underscore the urgent need for evidence-based policy directives, interventions, and support.