Reviewer’ s report
Title: Factors influencing women’ s sex work in a Lebanese sample Results of a case-control study
Version: 0Date: 11 Nov 2019
Reviewer: Teresita Rocha-Jimenez
Reviewer's report:
BMWH
Abstract and BackgroundRecommend avoiding generalizations such as "SW is viewed as a public problem" is this
everywhere? Is it a public health problem? A moral problem?Some of the issues associated SW could be cited to avoid this type of affirmations.
The background section includes many themes not in-depth discussed and several of the
affirmations included are not properly sustained or referenced. For example, the associationbetween substance use and sex work has only one reference and this only refers to addiction butnot coercion of substance use by someone else. Bar owners, managers, and clients may pressuresex workers to use substances. This theme should be included and considered in the analysis.
Furthermore, it is not clear where the studies cited were conducted. If this is in Lebanon or similar
countries this should be stated. It is problematic to make affirmations of structural complex factorssuch as violence, absence of parental supervision, depression, etc. specifically if these are being
analyzed to determine a pathway into the sex trade.
An in-depth revision of the background is recommended so it is properly justified why you are
including and analyzing the independent factors that you used. Furthermore, details of the sexwork context in Lebanon are needed to understand why the participants are entering into the sextrade and how they may be different from the control group.
Authors affirm:"sex work offends cultural-moral standards and spreads sexually transmitted
diseases". However, there are no studies cited and these affirmations include stigmatizinglanguage. These affirmations are not true in the entire world and male clients are often the onesresponsible for the transmission of HIV and other STIs. It is recommended to increase the qualityof the references, studies, and to use a neutral language. Suggestions include not usingaffirmations or generalizations, find papers and studies that have found such associations and citethem.
Authors affirm that there is no study of this nature but no studies or references are supporting this.
It is methodologically impossible to prove that some elements are leading to something else(causality) if you are not conducting a longitudinal study. Revising the aim of this study is critical.
Methods
It is not clear why you are analyzing the independent factors included in this study (trauma,
partner abuse, etc.). In the background there is only one paper cited that found association of childabuse with sex work among a cohort of drug users. However, it is not clear why you chose thesefactors and not other relevant factors (SES, education, underage entry, etc.)
An important element that is not included in this paper is the socioeconomic status of the
participants. The background mentions that women engage in return of money but this element is
not analyzed anywhere in the analysis. Socioeconomic status should be included in the final
model.
This study design is highly problematic to understand the pathway to sex work. First, because
there are innumerable variables that could have played into such outcome for example coercion,underage entry, sex work in the family, etc. A longitudinal study would have been more suitable tostudy this and even so it is hard to compare pathways to such a complex activity.Secondly, because these participants' study were recruited in prison there may be othercomplexities that are not being considered in this analysis. This should be clearly stated in thelimitation section and an extended description of the circumstances of how these participants wereinvited to participate should be included. There are almost no details of how participants wereinvited to participate in this study. There are no details of how they were invited, by whom, howthey were compensated if they had the option of not participating, who did the interviews, howtheir confidentiality was protected, if they had access to psychological help as they were beingasked about traumatic experiences, etc.
How was sex work defined and how women self-reported such activity?
There are no details of the temporality of the scales, alcohol and drug use, was this in the past
month, past year, was any of this diagnosed by a Doctor? Alcoholic is not an academic term and
the scale used does not assess such behavior. Revise.Is the anxiety measured for current anxiety? Anxiety may be present among all of the participantsas they are being interviewed in prison. This should be considered and included in the limitations.
ResultsAlcohol use could be associated with stress, anxiety score, depression, psychological child abuse,
etc. Thus this may be mediating the association between SW and all of those independentvariables. This should be analyzed (assess for interactions, multicollinearity) and stated in youranalyses. As it is currently presented, it arises many statistical issues as well as analytical. It isproblematic to not control for education, age, SW age entry, SES. These variables should be allpresented and considered in the final model.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
NoAre the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you recommend an
additional statistical review?If an additional statistical review is recommended, please specify what aspects require furtherassessment in your comments to the editors.
I recommend additional statistical reviewQuality of written English
Please indicate the quality of language in the manuscript:
Not suitable for publication unless extensively editedDeclaration of competing interests
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