Title: Self-rated health and quality of life in female sex workers with substance use disorders
in Tehran, Iran
Version: 3 Date: 30 Aug 2022
Reviewer's report:
Dear authors,
Thank you for your study which represents an important inquiry into the quality of life of sex
workers with substance use disorders in Tehran, Iran. While the study and its subject matter
are interesting, there is some lack of clarity in its Background and Discussion sections which
would benefit from greater referencing and clarification before this manuscript is ready for
publication. Importantly, the factors of sex work criminalization and sex work stigma have
been well documented in impacting the quality of life and health outcomes among sex workers
globally, yet these major factors are not discussed within this article. The authors have engaged
largely with Iranian literature - it would be beneficial to engage with more international literature
given the international scope and audience of BMC Women's Health. I recommend adding
further background on how sex work legislation in Iran, sex work criminalization, and sex work
stigma relate to the study's approach and its findings. I further recommend adding additional
references from the international sex work literature.
Minor specific comments are below:
Introduction section
'In LMICs poverty, low education, violence, alcohol and drug use, human immunodeficiency
virus (HIV), and stigma and discrimination are identified as key risk factors in females sex work'
- This sentence would benefit from clarification and references. Are the listed factors associated
with initiation of sex work? Or are they issues faced by female sex workers? Please clarify this
sentence.
'This review  found ...' - What review? Please clarify.
'If SUDs is added to the lives of women, more risk factors  can be listed...' - Risk factors for
what? Initiation into sex work? Risk factors for poor health outcomes? Please clarify this.
'No doubt,  women with SUDs have many health-related concerns...' - 'No doubt' isn't appropriate
to say for this untested assertion. It would be more appropriate to say 'It is possible that women
with SUDs have additional health-related concerns, and that their QoL may be more impaired
due to the impact of sex work on their self-perceived health status, yet limited research has
explored this.' What is the research gap that this paper is aiming to address? It would be helpful
to clarify that here for the reader.
'It has been shown that the most important dimension of a sex worker's life depends on her
damaged social relationships (17);' - This is an extremely strong assertion to make and features
only one reference - what about the impacts of sex work criminalization and sex work stigma?
These are major factors which have been robustly documented across the global sex work and
public health literature as critical determinants impacting sex workers' lives. Please revise and
include adequate references for this assertion.
Findings section
'In addition to sex work, most of them had other jobs and sources of income (80.1%). ' - It says
here that 80.1% had other jobs and sources of income, but in Table 1, it says 'Employment' and
lists 80.1% under 'no'. This is very unclear - please revise and clarify.
Discussion section
'In Iran, in addition to the social exclusion of this group of women, FSW themselves seem to
play an important role in their own isolation. In terms of isolation, our experience with Iranian
FSWs shows that they do not consider good health to be their right, and do not strive for a high
quality of life, while they must try as other citizens to receive health services and live better
lives' - Is it fair to saw that FSW play an important role in their own isolation? What influences
FSWs to not consider good health to be their right? This section is missing a discussion of sex
work stigma. Sex work stigma affects sex workers' feelings of self-worth and belief that they
deserve good health and a good life. I suggest that a richer discussion of sex work stigma is
needed in this section, as well as deeper engagement with the literature.
I would be pleased to review a subsequent draft of this important study after it has been revised
to present further background on sex work legislation in Iran, sex work criminalization, and
sex work stigma, as well as adding additional references from the international literature on sex
work and public health.