Archives of Sexual Behavior https://doi.org/10.1007/s10508-022-02405-5 ORIGINAL PAPER Impact of the COVID‑19 Health Crisis on Trans Women and Cis Men Sex Workers in Spain Juan M. Leyva‑Moral1 · Juliana Castro Ávila2 · Marta Villar3 · Beti López4 · Héctor Adell5 · Mercè Meroño4 · Kevin Santander3,6 · Laia Ferrer7,8 · Jocelyn Mesías‑Gazmuri7,9 · Rocío Astudillo Alonso10 · Daniela Rojas Castro11 · Jordi Casabona7,9,12 · Cinta Folch7,9,12 Received: 16 February 2022 / Revised: 14 July 2022 / Accepted: 17 August 2022 © The Author(s) 2022 Abstract The objective of the study was to describe the impact of the COVID-19 pandemic on sex workers in accessing health and social services. A qualitative study was conducted using semi-structured interviews with 29 participants in Barcelona, Spain. Data were analyzed using thematic analysis. Four themes were identified: (1) impact of COVID-19 on physical/mental health, (2) barriers and facilitators to health/social service access, (3) health decision-making, and (4) suggestions for future pandemic situations. Barriers to accessing health services were structural. Non-governmental organization support was the main facilitating factor. A person-centered, intersectional approach is suggested for future practice, considering co-occurring syndemic factors. Keywords Sex work · COVID-19 · Determinants of health · Transgender · Trans women · Qualitative research Introduction scarce education that some health professionals have concern- ing working with such communities (Brookfield et al., 2020; Trans women (TW) and cisgender men (CM) sex workers (SW) Leyva-Moral et al., 2020, 2021). HIV and other STI screen- have a high burden of human immunodeficiency virus (HIV) ing, counseling, and treatments that are accessible in health and other sexually transmitted infections (STIs) worldwide. services are poorly adapted to the needs of SW (Brookfield It is higher than that of other SW, suggesting the existence of et al., 2020). Consequently, these people experience different unique challenges for this group when accessing healthcare types of discrimination due to their sexual and gender identity (Beyrer et al., 2015). Specific barriers to accessing the health or the stigma related to sex work (Baral et al., 2015; Brookfield system include stigma and discrimination, in addition to the et al., 2020). Furthermore, HIV-related stigma is an additional 8 * Juan M. Leyva‑Moral Departament d’Igualtat i Diversitat Ciutadana, Ajuntament de juanmanuel.leyva@uab.cat Mataró, Mataró, Spain 9 1 Institut d’Investigació Germans Trias i Pujol, Badalona, Spain Nursing Department, Faculty of Medicine, Grup de Recerca 10 Infermera en Vulnerabilitat i Salut (GRIVIS), Universitat Departament de Salut | Generalitat de Catalunya, ASSIR Autònoma de Barcelona, 08193 Bellaterra, Spain Esquerra Barcelona, Servei Trànsit Barcelona. Institut Català 2 de La Salut, Barcelona, Spain Coalition PLUS, Paris, France 11 3 Coalition PLUS, Paris, France Stop Sida, Barcelona, Spain 12 4 Centro de Investigación Biomédica en Red de Epidemiología Fundació Àmbit Prevenció, Barcelona, Spain y Salud Pública (CIBERESP), Madrid, Spain 5 NGO Stop Sida, Barcelona, Spain 6 Clinical Instructor at Nursing Department, Universtiat Autònoma de Barcelona, Barcelona, Spain 7 Departament de Salut, Generalitat de Catalunya, Centre d’Estudis Epidemiològics Sobre Les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT), Badalona, Spain 13 Vol.:(0123456789) Archives of Sexual Behavior barrier to HIV testing, leading to delayed diagnosis and access Materials and Methods to treatment (Brookfield et al., 2020). On the other hand, the limited civil, political, economic, social, and cultural rights This qualitative exploratory study was approved by the Ger- that migrants have, guarantees the marginalization of migrant mans Trias i Pujol University Hospital Ethics Committe SW, as their labor is unrecognized, if not directly criminalized, (Badalona, Spain). This was conducted between November in host countries (Global Network of Sex Work Project, 2018). 2020 and February 2021 using the framework of the SexCo- In this sense, their immigration and social status as part of an hort project, a longitudinal study of TW and CM SW. This ethnic minority must be considered in addition to the differ- study was performed in collaboration with the EpiC Project, a ent forms of discrimination they experience (Earnshaw et al., multi-country, cross-sectional, community-based study assess- 2013; Logie et al., 2011). The European Network for HIV/STI ing the impact of the COVID-19 health crisis on populations Prevention and Health Promotion among Migrant Sex Workers at risk to or living with HIV and hepatitis C virus (HCV), and emphasized that migrant SW have greater difficulty access- on people who work with these populations in community ing health and social care due to social exclusion or isolation settings. TW and CM SW aged 18 years or older were purpo- (TAMPEP, 2019). sively recruited from two community-based centers in Bar- Members of key populations, including SW and transgen- celona. NGOs workers informed clients about the study and der people, were disproportionally impacted by COVID-19 provided information about how to participate. The qualitative (Meeting Targets and Maintaining Epidemic Control (EpiC), methodology allowed us to approach the phenomenon of the 2020). As one of the most marginalized communities, SW study in its entirety and helped us understand how it manifests are being left behind, as the measures adopted by the govern- itself and what factors are related (Polit & Beck, 2017). Data ments of Spain and Catalonia to face the health emergency were collected in Spanish through semi-structured face-to-face caused by COVID-19 (lockdown and social distancing) did interviews. Online interviews were also given as an option due not consider the needs of these populations. This can also be to the COVID-19 pandemic; however, the participants were seen in many other countries (Jozaghi & Bird, 2020; Platt et al., not amenable to this option. The interview script adapted from 2020; UNAIDS, 2020b). Lockdowns, self-isolation, and travel the EpiC Project was created by consensus among the mem- restrictions prevented them from working. Some were even bers of the research team and the community leaders. Several forced onto the streets and into destitution, where the risks discussion sessions were required until the final version was were heightened by the pandemic (ICRSE, 2020). For this completed. Given the methodology used, the script was open reason, they had to resort to charity and aid provided by NGOs to modifications and adaptations (Polit & Beck, 2017). Open- to cover some of their essential needs (Bernabé, 2020). In this ended questions explored the following: (a) knowledge and context, new barriers to health services access have appeared, perception of COVID-19, (b) experiences of sex work during such as the closure of sexual health services or interruptions lockdown, (c) specific health and social needs, (d) knowledge in the distribution of condoms or other sex practice-related of available help resources, (e) access to comprehensive medi- materials, among others (Álvarez García, 2020). Few stud- cal care, (f) resources search strategies, (g) main perceived ies have examined the social and structural determinants that barriers to access to care services, (h) sex work experiences, (i) affect access to the health system by TW and CM SW. There- discrimination in social or health services, and (j) experiences fore, the impact COVID-19 may have on access to prevention of institutional and individual violence. The sample questions and treatment services remains unknown (Beyrer et al., 2015; are provided in Table 1. Shannon et al., 2015). The analysis of barriers and facilita- The interviews were conducted at the facilities of two com- tors to health service access for TW and CM SW requires munities in Barcelona—(hidden for blinding purposes)—by approaches that go beyond individual factors, making it nec- three health technicians trained for this purpose by the prin- essary to cover a greater diversity of experiences and needs cipal investigator (PI). The interviews were audio-recorded through a research methodology that captures this complexity and transcribed verbatim immediately afterward. Field notes, (Levesque et al., 2013; Ma et al., 2017; Wanyenze et al., 2017). which mainly included observations, reflections, and clarifica- Qualitative methodologies have previously been used success- tions during the interviews discussed with the PI, were also fully to identify and describe barriers to accessing social and collected and included in the data analysis. In addition, the health services (Sevelius et al., 2016). It must be noted that sex PI met with the interviewers periodically to resolve doubts work in Spain is legal, however not recognized as a job from or incidents, verify that the interviews were understood, and which access to free health service, sickness leave and other the data collected were relevant. The average duration of the rights recognized for all workers. This study aims to describe interviews was 45 min. Participants were recruited intention- the perceived impact of the COVID-19 pandemic on TW and ally and received an incentive of 20 euros. CM SW, as well as to assess the barriers and facilitators to Before starting the interviews, the participants received health and social service access during the pandemic. detailed information about the study and were able to ask 13 Archives of Sexual Behavior Table 1  Sample questions from the semi-structured interviews 1. How would you describe your current physical and emotional health? 2. What worries you about your current state of health? Why? Have your health concerns changed due to the COVID-19 health crisis? How? 3. In what way do you think COVID-19 has changed the way you use health services? 4. What have you missed during this time of pandemic and lockdown related to your health and social needs? 5. How was the care received during the pandemic? Have you accessed telemedicine consultations? How was it? 6. Tell me about your day-to-day time since the beginning of the crisis and/or confinement. How did you feel during confinement? 7. How do you think COVID-19 has affected sex work? Why? 8. What impact does this health crisis have on discrimination and stigmatization toward sex workers? 9. What do you think of the measures adopted by the Government to face the COVID-19 health crisis? 10. What could NGOs do to better adapt to the needs of sex workers during the COVID-19 health crisis? questions before signing the informed consent. No identifying team reviewed and verified the analytical process and the data were collected. Moreover, the names of the participants results, which had also been previously agreed upon with the were replaced by an alphanumeric code (Participant 1 = P1 and experts on the topic. All authors were involved in working with so on). Interviews were conducted until the data were saturated vulnerable populations and some of them are visible members (i.e., when the data collected and analyzed did not offer new of the LGBTQIA + community. Four researchers were actively results, informational redundancy occurred) (Sandelowski, caring for sex workers during data collection. Coordination 2008). To have a diverse sample, years of practicing SW, the meetings were held to discuss how personal identities and administrative situation in Spain (regular, irregular, or pend- occupations of the research team could shape data collection ing), HIV and hepatitis C serological status, and gender iden- and analysis. Efforts were made to identify personal assump- tity (cis, trans, queer, etc.) were taken into account. tions and preconceptions and bracket them. Constant access to Data were analyzed thematically following the method the principal investigator was provided to debrief and discuss proposed by Braun and Clarke (2012) with the support of any doubt or concerns. the Atlas.tiV8 software. Thematic analysis is an approach for analyzing qualitative data to answer broad research questions. It is a flexible analytical method that does not pretend to be Results neutral since researchers may influence any analysis. Thus, the final product is one or more themes that explain people’s Twenty-nine CM and TW SW were interviewed. Their main experiences, perceptions, and points of view regarding the phe- socio-demographic characteristics are shown in Table 2. nomenon studied (Braun & Clarke, 2012). Verbatims were Four themes were identified in the data regarding the impact translated into English and verified by two bilingual research of COVID-19 on their health status and access to health and team members to insure the translated verbatims retained not social care. Exemplar quotations were chosen to illustrate these only syntax but also the original meaning. First, several read- themes. ings were made to become familiar with the content of the data. Second, descriptive codes were assigned to the differ- Physical and Mental Health Challenges Faced ent identified contents. Third, these codes were grouped into During COVID‑19 categories based on their similarities and differences. Finally, the results obtained were discussed by the research team in The participants stated that the confinement and pandemic several discussion sessions until an agreement was achieved. harmed their emotional health. Their socialization and adapta- The Consolidated Criteria for Reporting Qualitative Research tion patterns have changed, and loneliness has been a part of the (COREQ) checklist was used in this study (Tong et al., 2007). new situation in many cases. Labor and economic difficulties Throughout the process, the rigor criteria proposed by Guba have also generated psychological complications. Emotional (1981) and Guba and Lincoln (1994) were considered. The fragility is evident given the uncertain future concerning their entire research process was closely and continuously moni- employment situation as SW and their economic situation. In tored to achieve reliability, paying attention to the accuracy of addition, they have a difficult situation due to their profession, the transcripts and comparing them with their corresponding in which they had to live daily with structural violence due to audios. Similarly, the transcripts were read several times to their multiple risks (such as non-regularized work, job instabil- guarantee the fidelity of their contents. To verify the verac- ity, migrant status). This situation has been accentuated during ity and realism of the categories identified, three experts in the COVID-19 pandemic, directly impacting the difficulty of qualitative methodology that were not members of the research working and maintaining oneself. 13 Archives of Sexual Behavior Table 2  Participants’ characteristics Agea 33.9 ± 8.4 Years as a sex ­worker1 9.9 ± 9.4 n % Gender Trans woman 20 69.0% Cis man 6 20.7% Queer 2 6.9% Non-binary 1 3.4% Country of origin Latin America 26 89.7% Spain 3 10.3% Arrival to Spain After 2010 5 19.2% Before 2010 21 80.8% Immigration status Regular 12 41.4% On-going 11 37.9% Non-regular 6 20.7% Health insurance Government 26 89.7% Private + Government 3 10.3% HIV ­statusb Positive 19 65.5% Negative 10 34.5% HCV status ­VHCc Negative 27 93.1% Unknown 2 6.9% a Mean ± Standard Deviation; bHuman Immunodeficiency Virus; cHepatitis C Virus Emotionally, there are moments when I feel a bit down consumption due to the isolation, while the other initiated and and melancholic because of the situation we are living maintained it as it was their only way of managing sadness. in now. It is more on the emotional side. Physically, I When [confinement] began, I felt very depressed. I did see myself, and I consider myself to be doing well. (P11. not want to get [sick] or have someone else taken from Trans woman) me. But then, you feel bad and experience a low mood, I am concerned about the situation. The bars are going and you’re stuck in the house. The house falls on you. to close; they will possibly close everything on Friday, (P9. Trans woman) which makes me think more about what we have to do. During the confinement, I felt very sad and stressed We will have to go out and find lives ourselves. We do because of my situation and my family’s and friends’ not have any help. (P3. Trans woman) situations. People were dying worldwide, and I was very Both confinement and the pandemic itself have negatively scared. I was also upset because I couldn’t work and pay impacted the mental health of TW and CM SW in Barcelona. my rent. Then I tried drugs [tina], and that’s where it all First, social distancing forced them to separate from their loved started. (P5. Cis man) ones. Moreover, the possibility of COVID-19 transmission and Naturally, the participants struggled to get out of the nega- the fear of infecting other people prompted self-isolation. Epi- tive emotional situation using their personal and professional sodes of anxiety, depression, mistrust, anguish, sadness, lone- resources. Their sense of hope helped them continue with life liness, boredom, emotional lability, and fear were described. and cope effectively with the situation. They longed to return Two of the participants used drugs during this period. Their to their pre-pandemic social interaction, reunite with their accounts were completely opposite: one substantially reduced friends, enjoy their families, and get back to work and earn an 13 Archives of Sexual Behavior income again. They also communicated with their loved ones So, my plans for my sexual health were disrupted due to through video calls. It made their days more bearable. the crisis that we are going through. (P12. Trans woman) I started talking to my friends. We had video calls with Most participants indicated that COVID-19 had little several girls, and we talked about things there. It was impact on their physical health. Their follow-up and control nice to share our stories when we were disconnected visits with family doctors, nurses, and other specialists were from most of the outside situation. (P1. Trans woman) substantially reduced or replaced by telemedicine, which was well-received despite their preference for the traditional face- The measures implemented by the Government of Spain to-face format. The dispensing of medicines was also easier and Catalonia, mainly lockdown and social distancing, were due to telemedicine since treatment prescriptions for antiretro- described as unsatisfactory. The needs of SW were not consid- viral, hormone, and antihypertensive drugs could be renewed ered since it is a non-legal profession. Moreover, the closure without incident. Social, emotional, and health incidents were of bars and nightclubs along with other measures to reduce covered by NGOs given that the social services had collapsed social interaction directly affected their work and generated a and since SW already knew their effectiveness and how to loss or significant reduction in income. These decisions made access their services. them feel discriminated against, an experience they have also felt within the neighborhood, specifically when they take cli- I got a good response from the hospital. Visits had been ents home or go out to exercise. Some of the participants also canceled, but they contacted me via email and phone. employed teleworking; however, it was not widely practiced. One time, the pills were missing, but I could go to the pharmacy to pick them up. [NGOs] already do it and are [The government has] not taken us into account, hon- always in a good mood. [They] are there to offer things. estly. In other words, there was no noticeable plan to help And I think the Government should help [them] more for [during lockdown], nor was it mentioned to us. They everything, [they] do because [they] do a very good job. never thought about what we’d eat, how we’d pay the [They] are very concerned about people. (P5. Cis man) rent, or how we’d help our children or our family. They were ready to let the “whore” fall as if she were not a The main barriers described by the CM and TW SW were person and didn’t have needs. (P4. Trans woman) their non-regular immigrant status and waiting lists for health service access. However, these aspects were not exclusive to Despite the conditions experienced by SW during confine- the pandemic since they were already present before the pan- ment and the pandemic, generally, physical deficiencies were demic. The public health system was described positively; not felt, except weight gain and headaches. Some participants however, access to it was long and complex. even stated that the pandemic became an opportunity to per- form better health self-care and adopt healthier lifestyle habits. All immigration procedures and appointments stopped [during COVID-19 pandemic]. I could not renew my I looked for ways to entertain myself within those four card or add my fingerprint. I was due in June, and I have walls by exercising, reading, and getting up a little ear- been trying to book an appointment these past months lier. (P13. Trans woman) through the internet, and nothing happened. Everything stopped. (P14. Cis man) Challenges and Successes Accessing Health and Social Services The support received by the participants from NGOs solved most of their basic needs efficiently (e.g., case management, Aside from some exceptional experiences, confinement nega- food, housing, and bureaucracy for changing their name). They tively impacted their access to prevention and health services, also received help from the state social workers, mainly finan- particularly regarding medical visits that were canceled or redi- cial and help with health insurance procedures. However, these rected by telephone. In some cases, access to pre-exposure experiences have not always been satisfactory, mainly due to prophylaxis (PrEP) was difficult since the prescribing entities transphobic situations or the system’s slowness. Despite the were closed. difficulties experienced, they appreciated the help extended since they were aware of the seriousness of the problem and It was impossible to get an appointment for the GP – the lack of resources and professionals. impossible. I had to get a shot for my hormone issues, and they told me that I had to call them. It was really The city council also treats me well now, because I had difficult to access them. (P18. Trans woman) many problems before. The social worker did not treat Before COVID-19, I had planned to start taking PrEP, me as a trans woman; she treated me as a man. I don’t and my first visit was 15 days ago, it took a long time – know why – maybe because I had no experience. (P18. like four months – for them to get me an appointment. Trans woman) 13 Archives of Sexual Behavior An NGO helped us too. Well, they gave us food and I went back to work in May but, obviously, with the pre- helped us when the coronavirus quarantine was at its cautions, using alcohol, hand disinfection, and all those peak. It was a sex workers’ union. (P1. Trans woman) kinds of things. As I say, all for biosecurity. (P19. Trans Thank you for always attending to me. You are always woman) there when I write; thanks to you and the NGO, I have The isolation measures had a direct negative impact on the all we talked about. I can only thank you since you help participants’ labor sphere. The social distance imposed led those that the Government does not help. You do not to a loss of jobs and a significant economic decline that, on have it easy at all, from what I have heard. (P5. Cis man) numerous occasions, necessitated the help of community enti- Despite the difficulties encountered, satisfaction with the ties and social services. Many CM and TW SW had no money current healthcare system is generally very high. Their appre- to pay rent, bills, or food. The pandemic plunged some of the ciation for having a healthcare system that meets their physical, participants into a situation of greater risk and, in some cases, emotional, and social needs, in addition to sexual health, is forced them to devise new forms and places of work for sur- evident. Satisfaction with health professionals was also high. vival. Despite their intention to respect safety measures, the use Except for a specific episode of transphobic discrimination, of a mask was impossible in intimate encounters, especially at the public system solved their health doubts and offered them the express request of clients. Likewise, during the lockdown, prevention and cure options in most cases. Many of the par- some CM and TW SW accepted risky practices for fear of not ticipants came from countries where access to health services being able to support themselves. Even access to condoms was was difficult and slow. Therefore, the system’s failures were limited during the pandemic due to the temporary closure of minimum compared with the health systems of their countries NGOs. This increased the risk of acquiring STIs. of origin. You realize that you have to expose yourself because it I have had a good experience with health professionals, is the only way to survive. So, for example, we did not and they advise me on many things. (P29. Cis man) have an option other than making physical contact, and It is difficult to make a comparison when you come from if you don’t, you starve. So, in my case, I resigned […]. I a country with so many needs to a country with higher continued to attend to clients because I won’t say no, but coverage. So, it’s hard to compare, you understand? I used a hydroalcoholic gel, wore a mask, and asked the Because when you come to a country where there are client to shower first... Of course, there were no kisses, so many things, there is a lot of bureaucracy for every- no blowjobs – none of that. Straight to [intercourse] and thing. If you need an appointment, you must stand in always using a condom. (P8. Trans woman) line, because there are many things. So, it seems to me Taking care of their health, both general and sexual, was that I see progress. Why? It is not conformism; I simply part of a common practice that was already incorporated before consider my quality of life to be improved since I have the pandemic, such as the use of condoms, hygiene, medical been in Spain. (P7. Trans woman) check-ups, diet, and exercise. They also knew that the com- munity entities were always available to help them manage the Engagement in Health Risks and Protective situation at all times. All the participants had also used their Behaviors services at one time or another. Although some CM and TW SW performed some service at Financial problems? Yes, of course. Fighting to raise rent home to counteract the economic deficiencies produced by money was difficult, but it was achieved. It was difficult. health measures, they clarified that they followed the preven- It made you expose yourself a little more, didn’t it? (P4. tive measures indicated by health authorities. Even among Trans woman) those who received clients at home, measures were employed I liked the accompaniment [of the NGO], making as far as possible according to the proposed indications, such friends, controlling for sanitation, and the treatment. as hand hygiene, use of hydroalcoholic gel, and ventilation. The possibilities of giving us prophylactics to take care These preventive measures were continuously carried out even of ourselves, psychological help, and everything. Eve- when the confinement period ended since the pandemic is still rything seemed fabulous to me. I have achieved what I underway. needed to. (P8. Trans woman) I use alcohol. I ask the client to wash himself or take a Given the difficulty of the situation, particularly in eco- shower, if necessary. I give clean towels to each client. I nomic and social terms, the participants decided that the best also change the sheets. So far, I have not had any symp- option was to get used to the new situation, understand what toms. (P13. Trans woman) was happening, and incorporate small, authorized interven- tions that allowed them to air their ideas and feel better, 13 Archives of Sexual Behavior such as going for a walk, talking with friends on the phone, Discussion avoiding crowds, and healthy eating. In addition, some of the participants incorporated online sex work into their profes- Our findings highlight how the COVID-19 pandemic has sional practice to survive in times of confinement and the impacted the bio-psycho-social health status of TW and CM pandemic safely. SW in Barcelona, as well as their access to health and social I started looking for webcam options to work with; I services during the pandemic. The measures taken by the Gov- started to see options for other things to say. I must get ernment of Spain entailed: (a) discontinuity of some health money from somewhere. If I don’t, I won’t survive. services, including some HIV and STI care services; b) dis- (P16. Trans woman) continuity in some associative and community services; c) I began posting videos on Only Fans® to see if some- Implementation, in some cases, of additional systems of care thing would come of it, and thus, provide a service. and follow-up of patients (e.g., telemedicine). The main dif- Even though it was very little money, at least it was ficulties in accessing and using health services in these popula- income. It is something that does not fulfill me, and tions during COVID-19 were structural, given the measures you have to be constant, but it is an option, and I use proposed by the Government (lockdown and social distanc- it. (P7. Cis man) ing). This is consistent with many international studies that reported that COVID-19 disruptions led to limited access to HIV/STIs and sexual and reproductive health services for SW Suggestions for Future Pandemic Situations: in most countries (Gichuna et al., 2020; Howard, 2020; SWAN Increased Resources for Promoting Wellness Among & ICRSE, 2020; UNAIDS, 2020a). Sex Workers This study shows that structural barriers to health care access are frequent among CM and TW SW even before the Participants requested a more comprehensive food dispens- pandemic. This finding is consistent with previous evidence in ing network to cover more people. As mentioned, CM and a different sociocultural context (Singer et al., 2020). Evidence TW SW were aware of the economic difficulties that NGOs shows that migrant sex workers experience important barriers have suffered for years. Consequently, they demanded more in accessing preventive and curative interventions, mainly due aid for these entities since it was they who provided most of to stigma, discrimination, and criminalization (Folch et al., the participants’ general and sexual health needs. 2008; Global Network of Sex Work Project, 2018). This study identifies that the main barriers to accessing health services for I think we need food, money, and a space to live in SW before COVID-19 are the CM and TW SW’s non-regular because I have a friend who gave her a room to be immigrant status and the waiting lists for health care access. It there, to pass the isolation period. Somewhere to rest, a must be noted that most of the sex workers in Europe — most safe place for sex workers to rest. (P24. Trans woman) prominently in the West, South and North Regions of Europe, I have known you for four years, and I feel comfort- are migrants. In Catalonia, the proportion of migrants among able here. But we still need more help. The city council a similar study among female sex workers 85%. Furthermore, should give you more subsidies so that you can help us the discriminatory experiences faced when accessing health more. (P23. Trans woman) services by some healthcare providers, and the difficulties in The demands varied based on individual interests or basic changing the registry name (in people with non-normative gen- needs ranging from increasing home care, expanding health der identities) increased the difficulties in accessing the system service facilities, specific screening of COVID-19 for SW, dis- or doing it satisfactorily. Therefore, the COVID-19 pandemic tribution of financial aid to SW, to accommodation and other has emphasized the existing structural violence experienced telemedicine options. Colleagues were also urged to fight for by TW and CM SW, mainly because of their multiple risks SW rights, particularly reinforcing activism to legalize sex and the pandemic’s direct impact on their ability to work and work. provide for themselves. An intersectional approach (Crenshaw, 2021; Hill Collins & Bilge, 2016) to the phenomenon clearly Laws still need to be promoted and actually imple- identified several areas of oppression, such as gender identity, mented toward the transsexual community and those of immigration status, economic status, ethnic background, and us who work on this [SW]. Methods, laws, ways to help work. This lack of privileges has made TW and CM SW more the transsexual community should be sought. Perhaps exposed to violence, poorer health, and lack of government implementing laws for social and economic opportuni- support (Sanders, 2016). In contrast, feelings of satisfaction ties needs would help visibility. (P11. Trans woman) with the care provided, the closeness and professional commit- ment of health professionals, the specialized services in STIs, and the support received from non-governmental organizations 13 Archives of Sexual Behavior (NGOs), were identified as facilitating factors for health ser- profiles and the redundancy of the data obtained guaranteed vice access. Previous work has underscored the role of NGOs their credibility and dependability. Second, the collected data in helping people at risk to or living with HIV access and navi- corresponded to the sociocultural reality of the given context, gate the healthcare system in Spain (Gogishvili et al., 2021). which does not allow for the generalization of the findings. Despite the difficulties in accessing health services and pro- However, the research team suspects several of the findings fessionals face-to-face, telematic visits partially covered this are generalizable to other sex workers populations internation- limitation. However, as described previously in the literature, ally. Third, the interviews were conducted by three different the use of telehealth is not a 100% comprehensive solution to professionals, which could contribute to the variability dur- facilitate the provision of routine care. Moreover, the measures ing data collection. Various consensus and training meetings adopted, such as chronic medication delivery or health follow- were held to achieve homogenization of the data collection ups, suffered some delays (Lieneck et al., 2021a, 2021b). On methods; however, the methodology used allows for certain the other hand, NGOs had to respond flexibly to the needs of adaptations of the interview script based on the communica- their service users and had to adapt existing services to a set tive characteristics of the interviewees. Finally, there might be of previously unanticipated restrictions. Consequently, SW some information bias due to the sensitivity of the topic, which could access and maintain general and sexual health services; was minimized, to generate a safe environment of confidential- therefore, there was general satisfaction with these services ity and non-judgment by the interviewers. received during the pandemic. However, more personal help is necessary to cover economic deficiencies and aid so that NGOs can continuously respond to the needs of their users. Conclusions This has also been previously reported in other countries (Pinto & Park, 2020). The main difficulties regarding the access and use of health Furthermore, it should not be overlooked that in addition services in TW and CM SW during COVID-19 were struc- to reduced access to services, this crisis negatively impacted tural, given the measures adopted by the Government. Tele- the emotional health of SW. Their socialization patterns were matic visits partially covered the limitations of accessing modified, and they had to face labor and economic difficulties health services and professionals. However, there were delays that generated psychological complications. As shown, many in services, specifically in the delivery of chronic medication participants described feelings of loneliness and the need to and poor control of some health episodes. The main barriers be surrounded and cared for by their loved ones (mainly fam- to health service access for SW before COVID-19 were the ily and friends). In addition, a hard, uncertain, and difficult to illegal immigration situation and the waiting lists for health manage future compelled emotional breakdowns (Esterwood care services. Furthermore, the discriminatory experiences & Saeed, 2020; Gossett & Hayward, 2020; Leyva-Moral et al., of professionals and the difficulties in changing the registry 2015). Therefore, it is necessary to provide for the psychoso- name (in people with gender diverse identities) increased the cial needs of this group. difficulties in accessing the system or doing it satisfactorily. During the COVID-19 pandemic, SW showed themselves On the contrary, the closeness and professional commitment to be self-responsible even though they were forced to get used of health professionals and specialized services in STIs and to a new personal reality at work, were challenged financially, the support received from NGOs were identified as facilitating and had their physical and emotional health compromised. factors to health service access. Thus, the pandemic became an exercise in the self-manage- The COVID-19 pandemic has made it difficult to access ment of health, individual and collective responsibility, and health and social services, negatively impacting health solidarity. However, given the lack of privileges mentioned, experiences. SW were dissatisfied with the measures imple- some of them agreed to perform non-safe practices to gain mented during the pandemic by the Government (specially some income. Therefore, our data indicate that multiple, co- lockdown, changes in health centers dynamics, and no con- occurring syndemic factors (mainly basic needs not being cov- sider their needs during decision-making); they believe ered, mental health problems, and social isolation) placed these those measures were the main responsible of their labor and SW at a higher risk of COVID-19 and HIV/STIs, as reported economic problems. Consequently, this has also increased previously among street-based SW (Rogers et al., 2021). their risk of exposure to the virus. The adaptation of health This study has a series of limitations that must be consid- services, such as telemedicine, although considered better ered. First, the sampling used guaranteed the suitability of the than the cancelation of visits, was not sufficient to meet their profile of the participants in relation to the study’s objectives. health needs. Due to the interventions of NGOs, CM and TW However, it may have left some of the experiences of partici- SW were able to maintain their access to general and sexual pants who did not show interest unexplored, either because of health services during the pandemic and were satisfied with the difficulty of accessing the interviews or may be due to their these services. However, they call for more personal assis- discomfort with the topic discussed. Even so, the diversity of tance and aid for NGOs to continue providing health services 13 Archives of Sexual Behavior and support. Moreover, it should not be overlooked that this the article's Creative Commons licence and your intended use is not crisis had negatively impacted the emotional health of SW permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a since their socialization patterns were modified, and they had copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. to face labor and economic difficulties. Therefore, it is nec- essary to provide for the psychosocial needs of this group. These results highlight the importance of considering CM and TW SW as a target population for public health policy- References makers and health practitioners, given the risks identified in this study and previous evidence. Specific research on Álvarez García, A. (2020). La por al contagi de Covid, nou estigma per the risks and vulnerabilities by type of work will be needed a les dones en situació de prostitució. CCMA.CAT. https://​www.​ (street, online), due to the different practices and needs ccma.​cat/​324/​la-​por-​al-​conta​gi-​de-​covid-​nou-​estig​ma-​per-a-​les-​ dones-​en-​situa​cio-​de-​prost​itucio/​notic​ia/​30208​62/ of those who operate in the street and/or online may face. Baral, S. D., Friedman, M. R., Geibel, S., Rebe, K., Bozhinov, B., Diouf, Moreover, health promotion with a person-centered and D., Sabin, K., Holland, C. E., Chan, R., & Cáceres, C. F. (2015). intersectional approach is suggested for future research and Male Sex Workers: Practices, Contexts, and Vulnerabilities for practice. This will help provide easier access to health and HIV Acquisition and Transmission. Lancet (london, England), 385(9964), 260–273. https://​doi.​org/​10.​1016/​S0140-​6736(14)​ social services and promote non-discriminating/stigmatiz- 60801-1 ing environments. The work carried out by NGOs during Bernabé, M. (2020). Les prostitutes hem perdut la por al coronavirus the pandemic is an example of this type of approach that i a tot. ARA. https://​www.​ara.​cat/​socie​tat/​prost​itutes-​coron​avirus-​ responded to the difficulties of accessing the public health covid-​19_1_​11591​34.​html Beyrer, C., Crago, A.-L., Bekker, L.-G., Butler, J., Shannon, K., Kerrigan, system accentuated by the pandemic. Furthermore, determi- D., Decker, M. R., Baral, S. D., Poteat, T., Wirtz, A. L., Weir, B. nants of health—economic income, nutrition, and affordable W., Barré-Sinoussi, F., Kazatchkine, M., Sidibé, M., Dehne, K.-L., housing—must be considered in future research and prac- Boily, M.-C., & Strathdee, S. A. (2015). An Action Agenda for HIV tice; thus, dyad healthcare and economics must be studied and Sex Workers. The Lancet, 385(9964), 287–301. https://​doi.​org/​ 10.​1016/​S0140-​6736(14)​60933-8 together. Braun, V., & Clarke, V. (2012). Thematic analysis. In H. Cooper, P. M. Camic, D. L. Long, A. T. Panter, D. Rindskopf, & K. J. Sher (Eds.), Acknowledgements This work was supported by the Instituto de Salud APA Handbook of research in psychology. Research designs: Quan- Carlos III under Grant [PI18/01481] and cofunded by the Fondo Europeo titative, qualitative, neuropsychological, and biological. (Vol. 2, pp. de Desarrollo Regional. "Una forma de hacer Europa.” We would like to 57–71). American Psychological Association. thank all participants and all the member of the study SexCohort. Brookfield, S., Dean, J., Forrest, C., Jones, J., & Fitzgerald, L. (2020). Barriers to Accessing Sexual Health Services for Transgender Funding Open Access Funding provided by Universitat Autonoma de and Male Sex Workers: A Systematic Qualitative Meta-Sum- Barcelona. mary. AIDS & Behavior, 24(3), 682–696. https://​doi.​org/​10.​1007/​ s10461-​019-​02453-4 Data Availability Due to the nature of this research, participants of this Crenshaw, K. (2021). On intersectionality: essential writings. The New study did not agree for their data to be shared publicly, so supporting data Press. are not available. Earnshaw, V. A., Bogart, L. M., Dovidio, J. F., & Williams, D. R. (2013). Stigma and Racial/Ethnic HIV Disparities: Moving Toward Resil- ience. The American Psychologist, 68(4), 225–236. https://​doi.​org/​ Declarations 10.​1037/​A0032​705 Esterwood, E., & Saeed, S. A. (2020). Past Epidemics, Natural Disasters, Conflict of interest The authors report there are no competing interests COVID19, and Mental Health: Learning from History as we Deal to declare. with the Present and Prepare for the Future. Psychiatric Quarterly, 91(4), 1121–1133. https://​doi.​org/​10.​1007/​S11126-​020-​09808-4 Human Participants and Animals Approval was obtained from the ethics Folch, C., Esteve, A., Sanclemente, C., Martro, E., Lugo, R., Molinos, committee Comité de Ética de la Investigación del Hospital Universitari S., Gonzalez, V., Ausina, V., & Casabona, J. (2008). Prevalence Germans Trias i Pujol (#PI-20–301). The procedures used in this study of Human Immunodeficiency Virus, Chlamydia Trachomatis, and adhere to the tenets of the Declaration of Helsinki. Neisseria Gonorrhoeae and Risk Factors for Sexually Transmitted Infections Among Immigrant Female Sex Workers in Catalonia, Informed Consent Informed consent was obtained from all individual Spain. Sexually Transmitted Diseases, 35(2), 178–183. https://​doi.​ participants included in the study. org/​10.​1097/​OLQ.​0b013​e3181​5a848d Gichuna, S., Hassan, R., Sanders, T., Campbell, R., Mutonyi, M., & Mwangi, P. (2020). Access to Healthcare in a time of COVID-19: Open Access This article is licensed under a Creative Commons Attri- Sex Workers in Crisis in Nairobi, Kenya. Global Public Health, bution 4.0 International License, which permits use, sharing, adapta- 15(10), 1430–1442. https://​doi.​org/​10.​1080/​17441​692.​2020.​18102​ tion, distribution and reproduction in any medium or format, as long 98 as you give appropriate credit to the original author(s) and the source, Global Network of Sex Work Project (2018). Migrant Sex Workers. Brief- provide a link to the Creative Commons licence, and indicate if changes ing Paper. Available at www.​nswp.​org/​sites/​nswp.​org/​files/​brief​i ng_​ were made. The images or other third party material in this article are paper_​migra​nt_​sex_​worke​rs_​nswp_-_​2017.​pdf included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in 13 Archives of Sexual Behavior Gogishvili, M., Florez, K. R., Costa, S. A., & Huang, T. T. K. (2021). A Concerning Community-Based Organizations and Frontline Providers Qualitative Study on Mixed Experiences of Discrimination and Health- Ending the HIV Epidemic Within this Decade. AIDS and Behavior, 24, care Access Among HIV-positive Immigrants in Spain. BMC Public 2486–2489. https://​doi.​org/​10.​1007/​s10461-​020-​02893-3 Health, 21, 385. https://​doi.​org/​10.​1186/​s12889-​021-​10388-6 Platt, L., Elmes, J., Stevenson, L., Holt, V., Rolles, S., & Stuart, R. (2020). Gossett, C., & Hayward, E. (2020). Trans in a time of HIV/AIDS. TSQ: Sex Workers Must not be Forgotten in the COVID-19 Response. The Transgender Studies Quarterly, 7(4), 527–553. https://​doi.​org/​10.​1215/​ Lancet, 396(10243), 9–11. https://​doi.​org/​10.​1016/​S0140-​6736(20)​ 23289​252-​86651​71 31033-3 Guba, E. (1981). Criteria for Assessing the Trustworthiness of Naturalistic Polit, D. F., & Beck, C. T. (2017). Nursing research. Generating and assess- Inquiries. Educational Communication and Technology: A Journal ing evidence for nursing practice (10th ed.). Wolters Kluwer. of Theory, Research, and Development, 29(2), 75–91. https://​doi.​org/​ Rogers, B. G., Paradis-Burnett, A., Nagel, K., Yolken, A., Strong, S. H., 10.​1007/​BF027​66777 Arnold, T., Napoleon, S. C., Maynard, M., Sosnowy, C., Murphy, M., Guba, E., & Lincoln, Y. (1994). Sage handbook of qualitative research. Sage. Daley Ndoye, C., Holcomb, R., Schierberl Scherr, A., Pinkston, M., Hill Collins, P., & Bilge, S. (2016). Intersectionality. Polity Press. & Chan, P. A. (2021). Sex Workers and Syndemics: A Population Howard, S. (2020). Covid-19: Health Needs of Sex Workers are Being Vulnerable to HIV and COVID-19. Archives of Sexual Behavior, 50(5), Sidelined, Warn Agencies. BMJ (clinical Research Ed.), 369, m1867. 2007–2016. https://​doi.​org/​10.​1007/​S10508-​021-​01940-X https://​doi.​org/​10.​1136/​BMJ.​M1867 Sandelowski, M. (2008). Theoretical saturation. In L. M. Given (Ed.), ICRSE. (2020). The International Committee on the Rights of Sex Workers The SAGE encyclopedia of qualitative research methods (Vol. 2, pp. in Europe (ICRSE) monitored the impact of COVID-19 on sex workers 875–876). Sage. in Europe. http://​redli​ghtco​videu​rope.​org/ Sanders, T. (2016). Inevitably Violent? Dynamics of Space, Governance, Jozaghi, E., & Bird, L. (2020). COVID-19 and Sex Workers: Human Rights, and Stigma in Understanding Violence Against Sex Workers. Stud- the Struggle for Safety and Minimum Income. Canadian Journal of ies in Law Politics and Society, 71, 93–114. https://​doi.​org/​10.​1108/​ Public Health = Revue Canadienne de Santé Publique, 111(3), 406. S1059-​43372​01600​00071​005 https://​doi.​org/​10.​17269/​S41997-​020-​00350-1 Sevelius, J. M., Keatley, J., Calma, N., & Arnold, E. (2016). “I am not a Levesque, J., Harris, M., & Russell, G. (2013). Patient-Centred Access to man”: Trans-Specific Barriers and Facilitators to PrEP Acceptability Health Care: Conceptualising Access at the Interface of Health Sys- Among Transgender Women. Global Public Health, 11(7–8), 1060– tems and Populations. International Journal for Equity in Health. 1075. https://​doi.​org/​10.​1080/​17441​692.​2016.​11540​85 https://​doi.​org/​10.​1186/​1475-​9276-​12-​18 Shannon, K., Strathdee, S. A., Goldenberg, S. M., Duff, P., Mwangi, P., Leyva-Moral, J. M., Aguayo-Gonzalez, M., Palmieri, P. A., Guevara- Rusakova, M., Reza-Paul, S., Lau, J., Deering, K., Pickles, M. R., & Vasquez, G., Granel-Grimenez, N., & Dalfó-Pibernat, A. (2021). Atti- Boily, M. C. (2015). Global Epidemiology of HIV Among Female Sex tudes and Beliefs of Nurses and Physicians About Managing Sexual Workers: Influence of Structural Determinants. The Lancet, 385(9962), Health in Primary Care: A Multi-site Cross-sectional Comparative 55–71. https://​doi.​org/​10.​1016/​S0140-​6736(14)​60931-4 Study. Nursing Open, 8(1), 404–414. https://​doi.​org/​10.​1002/​NOP2.​ Singer, R., Crooks, N., Johnson, A. K., Lutnick, A., & Matthews, A. (2020). 641 COVID-19 Prevention and Protecting Sex Workers: A Call to Action. Leyva-Moral, J. M., de Dios Sánchez, R., Lluva-Castaño, A., & Mestres- Archives of Sexual Behavior, 49(8), 2739–2741. https://​doi.​org/​10.​ Camps, L. (2015). Living with Constant Suffering: A Different Life 1007/​S10508-​020-​01849-X Following the Diagnosis of HIV. Journal of the Association of Nurses SWAN & ICRSE. (2020). COVID-19 crisis impact on access to health in AIDS Care, 26(5), 613–624. https://​doi.​org/​10.​1016/j.​jana.​2015.​ services for sex workers in Europe and Central Asia - SWAN. https://​ 04.​006 swann​et.​org/​resou​rces/​covid-​19-​crisis-​impact-​on-​access-​to-​health-​ Leyva-Moral, J. M., Feijoo-Cid, M., Domingo, A. T., Ribas, B. P., Royes, R. servi​ces-​for-​sex-​worke​rs-​in-​europe-​and-​centr​al-​asia/ B., Castillo, M. M., Mercadé, J. N., & Aguayo-Gonzalez, M. (2020). TAMPEP. (2019). European TAMPEP. The European Network for HIV/ Exploration of Clients Living with HIV Needs for Reporting on Expe- STI Prevention and Health Promotion among Migrant Sex Workers riences with Sex. Nursing & Health Sciences, 22(3), 570–576. https://​ - Position Paper. doi.​org/​10.​1111/​NHS.​12696 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated Criteria for Report- Lieneck, C., Herzog, B., & Krips, R. (2021). Analysis of Facilitators and ing Qualitative Research (COREQ): A 32-item Checklist for Inter- Barriers to the Delivery of Routine Care During the COVID-19 Global views and Focus Groups. International Journal for Quality in Health Pandemic: A Systematic Review. Healthcare (Basel, Switzerland). Care: Journal of the International Society for Quality in Health Care, https://​doi.​org/​10.​3390/​HEALT​HCARE​90505​28 19(6), 349–357. https://​doi.​org/​10.​1093/​INTQHC/​MZM042 Lieneck, C., Weaver, E., & Maryon, T. (2021). Outpatient Telehealth UNAIDS, J. U. N. P. on H.-. (2020b). Feature Story: COVID-19 Must Implementation in the United States During the COVID-19 Global Uphold and Protect the Human Rights of Sex Workers. Pandemic: A Systematic Review. Medicina (Lithuania), 57(5), 462. UNAIDS. (2020a). Sex workers must not be left behind in the response to Logie, C. H., James, Ll., Tharao, W., & Loutfy, M. R. (2011). HIV, Gen- COVID-19. der, Race, Sexual Orientation, and Sex Work: A Qualitative Study of Wanyenze, R. K., Musinguzi, G., Kiguli, J., Nuwaha, F., Mujisha, G., Musin- Intersectional Stigma Experienced by HIV-positive women in Ontario, guzi, J., Arinaitwe, J., & Matovu, J. K. B. (2017). “When They Know Canada. PLOS Medicine, 8(11), e1001124. https://​doi.​org/​10.​1371/​ that you are a Sex Worker, You will be the Last Person to be Treated”: JOURN​AL.​PMED.​10011​24 Perceptions and Experiences of Female Sex Workers in Accessing HIV Ma, P., Chan, Z., & Loke, A. (2017). The Socio-Ecological Model Approach Services in Uganda. BMC International Health and Human Rights. to Understanding Barriers and Facilitators to the Accessing of Health https://​doi.​org/​10.​1186/​S12914-​017-​0119-1 Services by Sex Workers: A Systematic Review. AIDS and Behavior, 21(8), 2412–2438. https://​doi.​org/​10.​1007/​S10461-​017-​1818-2 Publisher's Note Springer Nature remains neutral with regard to Meeting Targets and Maintaining Epidemic Control-EPIC. (2020). Stra- jurisdictional claims in published maps and institutional affiliations. tegic considerations for mitigating the impact of COVID-19 on key- population-focused HIV programs. Pinto, R. M., & Park, S. (2020). COVID-19 Pandemic Disrupts HIV Con- tinuum of Care and Prevention: Implications for Research and Practice 13