Knowledge and Practice of Emergency Contraception among Female Sex Workers: A Global Scoping Review

Knowledge and Practice of Emergency Contraception among Female Sex Workers: A Global Scoping Review | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Knowledge and Practice of Emergency Contraception among Female Sex Workers: A Global Scoping Review View ORCID Profile M. Suchira S Suranga , K. Karunathilake , W. Indralal De Silva doi: https://doi.org/10.1101/2025.04.01.25325048 M. Suchira S Suranga 1 The Family Planning Association of Sri Lanka , Sri Lanka ; Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for M. Suchira S Suranga For correspondence: suchirasuranga{at}gmail.com K. Karunathilake 2 University of Kelaniya , Sri Lanka Find this author on Google Scholar Find this author on PubMed Search for this author on this site W. Indralal De Silva 3 University of Colombo , Sri Lanka Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Introduction Female sex workers (FSWs) face a high risk of unintended pregnancies and abortion. Emergency contraception (EC) serves as a critical option for pregnancy prevention especially in the circumstances such as condom failure, stealthing, and sexual violence. Limited research has focused on the knowledge and practices of EC among FSWs. This scoping review aims to synthesize available evidence on the knowledge and use of EC among FSWs. Methods This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. A comprehensive search was conducted across four databases; Lens.org, Dimensions, PubMed, and Google Scholar. Inclusion criteria covered qualitative and quantitative journal articles published between 2000 and 2024 that examined EC knowledge and use among FSWs. Thematic analysis was performed and descriptive statistics were applied where relevant. Results The initial search yielded 735 studies, with 633 unique records after deduplication. Title and abstract screening shortlisted 34 articles for full-text review, of which 16 were excluded due to lack of relevance. An additional six studies were identified through reference screening, resulting in a final set of 24 studies. Findings revealed low awareness and usage of EC among FSWs despite a high prevalence of intentional and unintentional condom breakages, stealthing, sexual violence, and abortions. Median prevalence of life time use was 27.5%. Key barriers included misconceptions, cost, stigma, and lack of service availability. Conclusion FSWs’ experience indicated significant unmet needs for EC, yet research on this issue remains limited. Expanding access, addressing misinformation, and integrating EC into reproductive health services for FSWs are critical for reducing unintended pregnancies and associated health risks. Additionally, there is a pressing need for further research focusing on EC among FSWs in diverse settings to inform targeted interventions and policy development. 1. Introduction Sex work is defined as the exchange of sexual services for money or its equivalent ( 1 ). It is a consensual sexual activity involving adults and young people of legal age, taking diverse forms across different countries and communities. The structure of sex work varies, ranging from informal, independent arrangements to highly organized systems ( 2 ). Inconsistent condom use ( 3 , 4 ), limited adoption of non-barrier contraceptive methods including Long-Acting Reversible Contraceptives ( 5 ) and EC ( 6 , 7 ) along with a high partner exchange rate ( 4 ), restricted access to healthcare ( 8 ), and lack of bodily autonomy ( 9 ) contribute to significant health challenges among FSWs compared to the general female population ( 6 ). These risks are further exacerbated by high levels of sexual violence ( 10 , 11 ), coerced sexual acts, and the intentional or unintentional breakage and slippage of condoms by clients during intercourse ( 12 , 13 , 14 ). As a result, FSWs face numerous occupational hazards, including an increased risk of HIV and other sexually transmitted infections (STIs), unintended pregnancies, and both induced and spontaneous abortions ( 5 , 15 ). Table 1 presents data on the lifetime prevalence of induced abortion among FSWs in selected countries, highlighting the significant reproductive health burden faced by this population. View this table: View inline View popup Download powerpoint Table 01: Lifetime Prevalence of Induced Abortion among FSWs in Selected Countries EC, also known as post-coital contraception, refers to methods used to prevent pregnancy within the first few days after unprotected or inadequately protected intercourse. It is intended for emergency use in cases of contraceptive failure or misuse such as missed pills or condom breakage as well as in instances of rape or coerced sex. However, EC does not provide protection against sexually transmitted infections (STIs), including HIV ( 27 ). For optimal effectiveness, EC should be used as soon as possible and within five days of intercourse. There are four main EC methods available globally: emergency contraceptive pills (ECPs) containing either levonorgestrel or ulipristal acetate, combined oral contraceptive pills (used in higher doses for EC), and copper-bearing intrauterine devices (IUDs), which are the most effective form of EC ( 28 ). World Health Organization (WHO) recommends that all women and girls at risk of unintended pregnancy have the right to access EC, and these methods should be routinely included within all national family planning programmes. Nonetheless, frequent and recurrent use of EC may carry potential risks for women with specific medical conditions. Additionally, it can lead to heightened side effects, such as menstrual irregularities, although it is worth noting that repeated use of EC is not associated with known health hazards ( 28 ). While most research on the sexual and reproductive health (SRH) of FSWs has primarily focused on their vulnerability to sexually transmitted infections (STIs), particularly HIV, as well as unintended pregnancies and abortions ( 6 ), there has been limited attention on the use of non-barrier contraceptive methods, especially EC. Our comprehensive literature search did not identify any systematic review, narrative review, or scoping review that specifically examines the use of EC among FSWs. Addressing this research gap, the present scoping review aims to analyze the knowledge and practices related to EC among FSWs globally and identify the knowledge gap. The findings will provide valuable insights for future researchers conducting in-depth studies on EC use among FSWs and will support policymakers in developing more inclusive and integrated policies and programs to address unintended pregnancies and abortion within this population. 2. Methods This scoping review on the knowledge and practices of FSWs regarding EC was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines ( 29 ). The research protocol was developed using PRISMA-ScR guidelines by the researchers and reviewed by 2 peer researchers who are familiar with Systematic Literature Reviews before finalized. A summary of the protocol is available as annexure 01. A comprehensive search was performed across four scientific databases and search engines; Lens.org , Dimensions, PubMed, and Google Scholar to identify relevant studies up to February 28, 2025. The search strategy incorporated Boolean operators to combine key concepts related to EC and FSWs, using the following terms: (“Sex Worker” OR “Prostitute*”) AND (“Emergency Contraceptive*” OR “Emergency Contraceptive Pill*” OR “Morning After Pill*”)*. Only peer-reviewed journal articles published between 2000 and 2024 were included in the review. We adopted a broad definition of FSWs, including any female engaging in transactional sex, either full-time or part-time, as well as communities of women known to practice sex work, such as female entertainment workers in Bhutan and Cambodia ( 15 ). Both qualitative and quantitative studies published in peer-reviewed journals between 2000 and 2025 were included in the review ( Figure 01 ). Download figure Open in new tab Figure 01: PRISM flow diagram for identification, screening and selection of studies After removing duplicate records, the remaining unique studies underwent a two-stage screening process, conducted independently by two reviewers. In the first stage, the reviewers screened titles and abstracts for relevance, resolving any inconsistencies through discussion. In the second stage, the full texts of shortlisted articles were assessed against the eligibility criteria, again independently by both reviewers, with discrepancies resolved through discussion. Additionally, the reference lists of all included full-text articles were reviewed to identify any missed studies, leading to the inclusion of six additional studies. For non-English articles, Google Translate was used to facilitate comprehension during the screening process. Data from the included studies were charted using a predefined extraction form developed in alignment with the review objectives. The form captured study characteristics, population details, and key findings related to knowledge and practices of emergency contraception among female sex workers. Two reviewers independently conducted data charting to reduce bias, resolving any discrepancies through discussion and consensus. The final dataset was reviewed collaboratively by the research team to ensure completeness and consistency before analysis. The data items and definitions included in the final data set is described in annexure 01. A formal critical appraisal of included studies was not conducted, in accordance with scoping review methodology; further details are provided in Annexure 01. The final data set of all included articles was synthesized using a descriptive and thematic analysis approach. Quantitative data, such as prevalence figures, was summarized using basic descriptive statistics while qualitative findings was grouped and analyzed thematically under predefined categories such as knowledge of EC among FSWs, use of EC among FSWs, responses to condom failure and stealthing in relation to EC, the role of EC in cases of rape and sexual assault, factors associated with its use, and reasons for not using EC. 3. Results The initial database search identified 735 potentially eligible studies, of which 633 were unique records after removing duplicates. Following the initial screening of titles and abstracts, 34 articles were selected for full-text review. During this stage, 16 articles were excluded, as three did not focus on FSWs, and 13 did not include information on EC. An additional six relevant studies were identified through reference list screening ( Figure 01 ), resulting in a final set of 24 studies included in the review (Annexure 02). 3.1. Knowledge of EC among FSWs Studies indicate that knowledge of ECs among FSWs is generally low, with only a few studies exploring their awareness and understanding of EC. While some FSWs are aware of EC, misconceptions regarding its correct usage, timing, and limitations are common across different regions. A cross-sectional study conducted among 819 FSWs in Uganda found that 67.9% of participants had heard about EC ( 30 ). Similarly, a study among 466 FSWs in Côte d’Ivoire revealed that only one-third of all women in the study (n = 154) had knowledge of EC as a method to prevent pregnancy ( 31 ). In China, a study focusing on adolescent FSWs reported that around 64% had heard of EC ( 24 ). A multi-country cross-sectional study found that awareness of EC was significantly higher in high-income countries, with 74.8% of respondents demonstrating knowledge, compared to 96.1% in low and middle income countries ( 32 ). Despite some level of awareness, studies highlight that FSWs often lack a comprehensive understanding of how EC should be used. A study conducted in Bahir-Dar town, North West Ethiopia, found that while 90% of the respondents had heard about EC, only 12% (n = 48) demonstrated a full understanding of its proper use ( 33 ). Another study from Ethiopia, which surveyed 346 FSWs, revealed that nearly half (52.9%, n = 183) had never even heard of EC. Among those who were aware, 38.6% (n = 63) mistakenly believed that EC could be used at any time, even after 120 hours following unprotected sex, illustrating widespread misconceptions about the method’s efficacy ( 34 ). The knowledge of EC in specific contexts also varies. A study in Bhutan among 179 women working in the entertainment industry found that more than three-fourths (78.0%) of respondents knew that EC could be used after unprotected sex. However, significantly fewer recognized its applicability in cases of condom breakage (15.9%) or sexual assault (13.6%). While 71.2% of respondents could correctly identify the appropriate dosage, only 58.3% knew the correct timeframe for taking EC after sex. Encouragingly, 68.9% were aware that EC does not protect against HIV or other sexually transmitted infections ( 7 ). Qualitative research further highlights the misconceptions surrounding EC use among FSWs. A study conducted in Kenya found that out of 30 respondents, only three knew about EC as an option to prevent pregnancy after condom failure. Some participants mistakenly believed that urinating immediately after condom failure would prevent pregnancy, demonstrating a critical gap in knowledge regarding effective post-coital contraceptive methods ( 12 ). 3.2. Use of EC among FSWs As shown in Table 02 , the current use of ECs among FSWs varies significantly across different countries. The lowest reported prevalence of current EC use was 3.1% in Uganda ( 30 ), while the highest was 21% in China ( 24 ). Similarly, the lifetime use of EC among FSWs ranged from 2.4% in India ( 35 ) to 50.7% in Nigeria ( 36 ), with a median of 27.5%, recorded in Swaziland ( 6 ). These findings align with a systematic literature review on abortion among FSWs, which reported that the lifetime prevalence of EC use among this population ranged from 2.4% in India to 38.1% in Kenya, with a median of 15.8% ( 15 ). Studies specifically examining the use of EC among adolescent and young FSWs (aged ≤20 years) are limited. A narrative review conducted on 2020 found that the proportion of FSWs below 20 years of age who have ever used EC was ranged from 5% ( 37 ) to 44% ( 24 , 26 ). View this table: View inline View popup Download powerpoint Table 02: Prevalence of Current and Lifetime Use of EC among Female Sex Workers 3.2.1. Responses to Condom Failure and Stealthing: The Role of EC Studies indicate that condom failure; whether through breakage, slippage, or intentional tampering by clients is a frequent occurrence among FSWs, posing significant risks for unintended pregnancies and sexually transmitted infections ( 14 ). The lifetime prevalence of condom failure among FSWs varies widely across different regions, ranging from 33% in China ( 39 ) to as high as 90% in Cape Town ( 13 ), with a median prevalence of 72% ( Table 03 ). The responses of FSWs to condom failure vary significantly, often depending on their level of knowledge about EC and access to healthcare services. A qualitative study conducted in semi-urban Blantyre, Malawi, among 40 FSWs found that only 3 of the 18 women who experienced condom failure stopped sexual intercourse completely and sought medical care, including EC. Instead, most engaged in less effective post-exposure actions such as douching, urinating, or squatting in an attempt to prevent pregnancy ( 44 ). View this table: View inline View popup Download powerpoint Table 03: Prevalence of Condom Failure among Female Sex Workers in Selected Countries A quantitative study conducted among 100 FSWs in Cape Town found that while 90% had experienced condom breakage and 85% had experienced condom slippage at some point in their lives, only 8% reported using EC afterward. Instead, 53% took no action, while others engaged in ineffective protective behaviors such as applying vaginal spermicidal foam (3%) or washing immediately (5%). Notably, 3% reported consuming alcohol or drugs to cope with the incident ( 13 ). A separate qualitative study among 30 FSWs in Kenya confirmed that condom failure was a frequent occurrence. Many women attempted to mitigate risk by ensuring correct condom use, providing their own condoms, and applying them themselves. In the aftermath of condom failure, some women sought medical attention, particularly for sexually transmitted infections, but very few mentioned EC as an option ( 12 ). Intentional condom tampering by clients and nonconsensual condom removal (stealthing) pose serious risks to the health and safety of FSWs, further increasing their vulnerability to unintended pregnancies and sexually transmitted infections ( 12 , 14 , 43 ). A qualitative study conducted in Kenya found that 81% of participants had experienced condom breakage or slippage during commercial sex. The study categorized condom failure into two main types: unintentional failures caused by factors such as inebriation, forceful thrusting, or incorrect condom use, and intentional failures attributed to deliberate actions by clients, such as covertly removing or puncturing the condom. Similarly, research in Malawi highlighted that a significant number of FSWs had encountered clients who deliberately removed condoms often under coercive circumstances ( 44 ). A study conducted in Greece among 71 FSWs reported that 63.5% had experienced stealthing, a significantly high prevalence that highlights the widespread nature of this violation ( 43 ). Responses to condom failure varied widely, with some women replacing the condom and resuming sex, while others resorted to ineffective protective measures like washing. Only a few reported using EC following condom failure ( 14 ). 3.2.2. Rape, Sexual Assault, and the Role of EC Sexual violence is a major public health concern and a violation of human rights ( 45 ). FSWs are at an increased risk of rape and sexual assault, often due to criminalization of sex work, lack of legal protection, and unsafe working environments. Many FSWs operate in isolated locations, such as dark alleys, abandoned buildings, or unfamiliar hotels, increasing their vulnerability to violent clients ( 10 ). Studies from different countries report high rates of rape and sexual assault among FSWs, with prevalence ranging from 10.9% to 57.9%, depending on the region and timeframe considered ( Table 04 ). FSWs who reported forced sex were 2.69 times more likely to experience an unwanted pregnancy compared to those who had not been raped ( 11 ). View this table: View inline View popup Download powerpoint Table 04: Prevalence of rape or sexual assaults among Female Sex Workers in Selected Countries Despite the high prevalence of sexual violence among FSWs, research on the use of EC following rape remains scarce. The limited studies available suggest that only a small proportion of survivors access EC after experiencing sexual violence. For instance, a study of 395 street-based FSWs in Ethiopia found that 24.3% had experienced rape in their lifetime, and 11.4% had been raped in the past year. None of the victims used condoms during the assault, and only 4 (4.2%) used EC post-rape ( 33 ). Similarly in Uganda, a study among 819 FSWs found that 172 (21.0%) had been raped in the past two years, but only 70 (40.7%) accessed EC after the assault ( 30 ). However, a qualitative study in Nepal recognized EC as a lifesaving intervention for FSWs who experience sexual violence. Supervisors acknowledged that post-rape EC was crucial but often underutilized due to barriers in access ( 10 ). Failure to use EC after unprotected forced sex increases the risk of unintended pregnancies among FSWs, particularly those not using modern contraceptive methods ( 30 ). 3.2.3. Factors Associated with Use of EC Several factors have been identified as influencing the use of EC among FSWs. A cross-sectional study conducted among 325 FSWs in Swaziland found that education level was significantly associated with EC use. Women with secondary education were nearly four times as likely to have used EC compared to those with primary education or less. Additionally, age was a strong predictor of EC use, with younger women being more likely to use EC. Women aged 25 years or older had lower odds of using EC compared to their younger counterparts. Marital status also played a key role in EC use. Single FSWs were significantly more likely to have used EC, with 34.9% of single women reporting EC use compared to 16.7% of ever-married women (p = 0.029). In fact, single women had more than three times the odds of using EC compared to those who had ever married. Income was another factor associated with EC use. Higher-income FSWs were more likely to use EC, particularly when the partner exchange rate increased (p = 0.006). Further, condom use and condom failure were strongly linked to EC use. Women who had not always used condoms in the past month were significantly more likely to have used EC (38.1% vs. 15.8%; p < 0.001). Similarly, those who had experienced condom failure in the past month were more likely to have used EC (40.7% compared to 23.1%; p = 0.001) ( 6 ). A national-level study conducted in Cameroon involving 2,255 FSWs also identified that a history of termination of pregnancy was associated with a higher likelihood of EC use. FSWs who had previously terminated a pregnancy were 34% more likely to have used EC compared to those who had not. Additionally, the study found that FSWs who had ever used EC were 2.7 times more likely to use non-barrier contraceptives (such as hormonal methods, intrauterine devices (IUDs), or sterilization) compared to those who had never used EC ( 38 ). 3.2.4. Reasons for Not Using EC Despite the potential of EC in preventing unintended pregnancies, many FSWs are reluctant to use it. A study conducted among 395 street-based FSWs in Ethiopia found that the majority (95.8%) did not use EC, citing a variety of reasons. The most common reason was reluctance, reported by 41.8% of participants, followed by fear of side effects (19.8%). Other barriers included difficulty in identifying clinics that offered appropriate services (12%), lack of money (10.9%), lack of awareness about EC (10.9%), and fear of stigma (7.8%) ( 33 ). A similar study in Bhutan revealed that 79.9% of respondents had concerns about the potential harm of EC to their bodies. The most prevalent concerns included its effect on future pregnancy (76.1%), side effects (70.2%), and an increased risk of HIV/STIs (69.4%) ( 7 ). 4. Discussion Despite the critical importance of EC for FSWs, only a few studies have examined their knowledge, attitudes, and practices (KAP) regarding EC globally ( 6 ). However, the need for EC among FSWs is acute due to high rates of sexual violence, condom failures, unintended pregnancies, and abortions experienced by this population. Research has shown that EC use can significantly reduce unintended pregnancies and abortions ( 50 ). However, where reported, EC use among FSWs remains low in many settings ( 51 ). Those from lower socioeconomic backgrounds, who are at the highest risk of unintended pregnancies, often face significant barriers to EC access, including cost and lack of availability ( 6 ). The strong association between condom failure, stealthing, and EC use suggests that condom breakage and slippage are key drivers of EC use among FSWs ( 12 , 14 , 44 ). These findings underscore the need for programmatic interventions that address condom failure, including ensuring access to EC as a backup method ( 6 ). Findings from this study confirm the high prevalence of sexual violence and forced sexual activity among FSWs ( 33 , 10 , 11 ). These results highlight the need for an integrated response to sexual violence, including immediate access to EC for survivors of forced sex ( 11 ). Strengthening post-rape care services and ensuring that EC is part of standard care protocols for sexual violence survivors could help mitigate the risk of unintended pregnancies. A comparative study among FSWs in Nigeria found that those who received targeted interventions were 2.22 times more likely to use EC than their baseline counterparts ( 36 ). This study demonstrated the effectiveness of educational and intervention programs in increasing EC uptake. Similar programs should be adapted and implemented in other settings to improve access and awareness among FSWs. However, it must be acknowledged that as FSWs are a marginalized and hard-to-reach population, reproductive health interventions, particularly those aimed at increasing EC access must be tailored to their unique needs ( 34 ). Social and behavior change interventions, delivered by peer educators or healthcare providers, could address misinformation, fears, and limited knowledge about EC. Additionally, efforts to promote dual-method contraception should emphasize the use of long-acting reversible contraception (LARC) alongside EC as a backup option ( 52 ). Healthcare providers play a crucial role in increasing EC awareness and uptake. Training programs should focus on improving providers’ counseling and communication skills, ensuring that they discuss the full range of contraceptive options, including EC as part of comprehensive reproductive health counseling ( 52 ). This is particularly important in cases of forced sexual intercourse ( 33 ) and condom failure ( 14 , 44 ). Given the high risk of unintended pregnancies and induced abortions in this population, ensuring access to EC is essential, particularly in the context of inconsistent condom use, frequent condom failure, and sexual violence. However, EC has a relatively high failure rate compared to other modern contraceptive methods and should not be relied upon as a primary method of contraception ( 27 ). Over-reliance on EC instead of more effective long-term contraceptive methods remains a concern in many populations ( 50 ) including FSWs (Lim et al., 2015). Through a comprehensive and systematic literature review, this study identified a significant gap in research on the KAP of EC among FSWs globally. Very few studies have specifically focused on EC use in this population, with most research on contraception uptake overlooking EC. Future research should prioritize a more in-depth examination of EC knowledge, attitudes, and practices among FSWs in diverse settings to develop effective, context-specific interventions. Legal frameworks governing sex work play a critical role in shaping female sex workers’ (FSWs) access to and use of EC. In fully criminalized settings, such as Swaziland and Uganda, FSWs face significant barriers including fear of arrest, confiscation of condoms, and provider stigma which lead to low EC utilization despite high rates of unprotected sex, condom failure, and sexual violence ( 6 , 30 , 53 ). Partial criminalization models, like the Nordic approach, similarly displace sex workers into unsafe conditions, perpetuate stigma, and discourage healthcare access, resulting in limited EC use and poor sexual health outcomes ( 53 ). In legalized systems, such as in parts of Australia and Europe, registered FSWs may benefit from structured healthcare access and improved EC availability, but those outside the legal framework due to licensing barriers or undocumented status remain excluded and underserved ( 54 , 53 ). In contrast, decriminalized environments like New Zealand and New South Wales demonstrate significantly better outcomes, including improved EC access, stronger peer-led outreach, reduced stigma, and lower rates of unintended pregnancy, indicating that decriminalization fosters an enabling environment for reproductive health ( 54 ). This scoping review has several limitations. One significant limitation is the lack of research specifically focused on EC use among FSWs, which resulted in a limited number of studies available for review. Furthermore, the included studies varied in design, methodology, and geographical context, which may have introduced inconsistencies in the findings and hindered the ability to draw broad generalizations. Additionally, some studies combined EC use with other contraceptive methods, making it difficult to isolate the specific knowledge and practices related to EC. Finally, due to the limited research in this area, there is a significant gap in understanding the contextual factors that influence EC use among FSWs, particularly in low- and middle-income countries. 5. Conclusion This study underscores low level of awareness and use of ECP with the median prevalence of life time use of 27.5% among FSWs. This indicates the critical need to enhance access to EC among FSWs due to the high prevalence of unintended pregnancies, induced abortion, and sexual violence, including rape and assault. Intentional and unintentional condom breakage, slippage, and stealthing by the clients further increase the risk of unintended pregnancies, yet knowledge and use of EC remain low. Limited research on EC use among FSWs at the global level hinders effective policy and program development. Addressing these gaps through targeted education, improved access to EC, and stronger protections against sexual violence is essential for safeguarding the reproductive health and rights of FSWs. Data Availability The data underlying the results presented in the study are available from the relevant research articles included in the list of references. External Funding Authors declare that no external funding. Conflict of Interest Authors declare that there are no conflicts of interest. Ethical Approval This study was based solely on secondary data and a review of existing literature, without the involvement of human or animal subjects; therefore, ethical approval was not required for this phase. However, ethical clearance for the broader research project, which includes a subsequent stage involving human participants, has been obtained from the Ethics Review Committee of the University of Kelaniya, Sri Lanka (UoK/ERC/MDS/2024/038). Use of Artificial Intelligence Assisted Technologies During the preparation of this work the authors used ChatGPT in order to improve the language and readability. After using this tool/service, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication. Author contributions SS played a key role in the conceptualization, data curation, analysis, and drafting of the manuscript. KK and IDS contributed significantly to the screening and selection of articles, provided ongoing supervision throughout the process, and were actively involved in reviewing and finalizing the manuscript. Annexure 01: Review Protocol Summary View this table: View inline View popup Annexure 02: Studies included for data charting View this table: View inline View popup Acknowledgements The authors express their sincere gratitude to the following individuals for their invaluable contributions to this study: Dr. KGS Priyashantha, Senior Lecture, University of Peradeniya, Dr. Ruchitha Perera, Executive Director of The Family Planning Association, for his expertise and guidance. Mr. Duminda Rajakaruna, Mr. Janaranga Dewasurendra, and Mr. Amal Bandara for their dedicated support and assistance. Dr. Lakshman Senanayake for his valuable insights and contributions to the research. These individuals played a crucial role in enriching the quality and depth of the study, and their collaboration is deeply appreciated. References 1. ↵ Harcourt C , Donovan B . The many faces of sex work . Sexually Transmitted Infections . 2005 ;: p. 201 – 206 . 2. ↵ WHO . Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries: recommendations for a public health approach . Geneva, Switzerland:; 2012. Report No.: ISBN 978 92 4 150474 4. 3. ↵ Wurth MH , Schleifer R , McLemore M , Todrys KW , Amon JJ . Condoms as evidence of prostitution in the United States and the criminalization of sex work . Journal of the International AIDS Society . 2013 ; 16 ( 1 ). 4. ↵ Manathunge, Barbaric, Mestrovic, Beneragama, Bozicevic . HIV prevalence, sexual risk behaviours and HIV testing among female sex workers in three cities in Sri Lanka: Findings from respondent-driven sampling surveys . PLoS One . 2020 ; 15 ( 10 ): p. 1 – 13 . OpenUrl CrossRef PubMed 5. ↵ Ampt FH , Lim MS , Agius PA , Chersich MF , Manguro G , Gichuki CM , et al. Use of long-acting reversible contraception in a cluster-random sample of female sex workers in Kenya . International Journal of Gynecology & Obstetrics . 2019 ; 146 ( 2 ): p. 184 – 191 . OpenUrl PubMed 6. ↵ Yam EA , Mnisi Z , Maziya S , Kennedy C , Baral S . Use of emergency contraceptive pills among female sex workers in Swaziland . Journal of Family Planning and Reproductive Health Care . 2016 ; 40 ( 1 ): p. 102 – 107 . OpenUrl 7. ↵ Pem D , Nidup T , Wangdi U , Pelzom D , Mirzazadeh A , McFarland W . Emergency Contraceptive Pills (ECP) Knowledge, Attitudes, and Practices Among Women Working in the Entertainment Industry and Men in the Trucking Industry , Bhutan. AIDS Behaviour . 2018 ; 22 ( 1 ): p. 121 – 124 . OpenUrl 8. ↵ Suranga MS , Samita S , Karawita DA . HIV Testing and Receiving Test Results by the Female Sex Workers; Retrospective Study using Data from Sri Lanka National HIV Prevention Programme . Sri Lanka Journal of Sexual Health and HIV Medicine . 2020 ; 6 ( 1 ): p. 15 – 24 . OpenUrl 9. ↵ Coast, Norris AH, Moore AM, Freeman . Trajectories of women’s abortion-related care: A conceptual framework . Social Science & Medicine . 2018 ; 200 ( 1 ): p. 199 – 210 . OpenUrl PubMed 10. ↵ Saud SK , Aryal B , Ranabhat CL . Experience of Violence and Health Issues among Female Sex Workers in Kathmandu . Contemporary Research; An Interdisciplinary Academic Journal . 2024 ; 7 ( 1 ): p. 117 – 137 . OpenUrl 11. ↵ Sherwood JA , Grosso A , Decker MR , Peitzmeier S , Papworth E , Diouf D , et al. Sexual violence against female sex workers in The Gambia: a cross-sectional examination of the associations between victimization and reproductive, sexual and mental health . BMC Public Health . 2015 ; 15 ( 270 ): p. 1 – 10 . OpenUrl CrossRef PubMed 12. ↵ Bradburn CK , Wanje G , Pfeiffer J , Jaoko W , Kurth AE , McClelland RS . Risky Business: condom failures as experienced by female sex workers in Mombasa, Kenya . Culture, Health & Sexuality . 2016 ; 19 ( 3 ): p. 395 – 404 . OpenUrl PubMed 13. ↵ Mukumbang FC . Actions of female sex workers who experience male condom failure during penetrative sexual encounters with clients in Cape Town: Implications for HIV prevention strategies . Southern African Journal of HIV Medicine . 2017 ; 18 ( 1 ): p. 1 – 9 . OpenUrl 14. ↵ Masvawure TB , Mantell JE , Tocco JU , Gichangi P , Restar A , Chabeda SV , et al. Intentional and Unintentional Condom Breakage and Slippage in the Sexual Interactions of Female and Male Sex Workers and Clients in Mombasa , Kenya. AIDS Behaviour . 2018 ; 22 ( 2 ): p. 637 – 648 . OpenUrl 15. ↵ Mehrdad K , Fatemeh T , Sheree S , Mohammad K , Hamid S , Courtney AM , et al. Global epidemiology of abortion among female sex workers: a systematic review, meta-analysis, and meta-regression . Annals of Epidemiology . 2023 ; 85 ( 1 ): p. 13 – 37 . OpenUrl PubMed 16. Shahmanesh M , Wayal S , Cowan F , Mabey D , Copas A , Patel V . Suicidal Behaviour among Female Sex Workers in Goa , India; The Silent Epidemic. Amarical Journal of Public Health . 2009 ; 99 ( 7 ): p. 1239 – 1246 . OpenUrl 17. Wayal, Frances C, Pamela W, Andrew C, David M, Maryam S . Contraceptive practices, sexual and reproductive health needs of HIV-positive and negative female sex workers in Goa, India . Sexually Transmitted Infections . 2011 ; 87 ( 1 ): p. 58 – 68 . OpenUrl Abstract / FREE Full Text 18. Katz KR , McDowell M , Green M , Jahan S , Johnson L , Chen M . Understanding the broader sexual and reproductive health needs of female sex workers in Dhaka , Bangladesh. International Perspectives of Sexual and Reproductive Health . 2015 ; 41 ( 4 ): p. 182 – 190 . OpenUrl 19. Karamouzian, Mirzazadeh, Shokoohi, Khajehkazemi, Sedaghat, Haghdoost AA, et al. Lifetime Abortion of Female Sex Workers in Iran: Findings of a National Bio-Behavioural Survey In 2010 . PLoS ONE . 2016 ; 11 ( 11 ): p. 1 – 12 . OpenUrl CrossRef PubMed 20. Todd CS , Nasir A , Raza SM , Scott PT , Strathdee SA , Botros BA. Todd CS , Nasir A , Raza Stanekzai M , Scott PT , Strathdee SA , Botros BA , et al. Contraceptive utilization and pregnancy termination among female sex workers in Afghanistan . Journal of Women’s Health . 2020 ; 19 ( 1 ): p. 2057 – 2062 . OpenUrl 21. Bautista TC , Mejía A , Leal L , Ayala CS , Sanchez JL , Montano SM . Prevalence of lifetime abortion and methods of contraception among female sex workers in Bogota, Colombia . Contraception . 2008 ; 77 ( 3 ): p. 209 – 2013 . OpenUrl CrossRef PubMed Web of Science 22. Delvaux Trs, Crabbe, Seng, Laga . The Need for Family Planning and Safe Abortion Services among Women Sex Workers Seeking STI Care in Cambodia . Reproductive Health Matters . 2003 ; 11 ( 21 ): p. 88 – 95 . OpenUrl CrossRef PubMed Web of Science 23. Lau JT , Mui LW , Tsui HY , Wong EH , Ho SP . Prevalence of induced abortion and associated factors among Chinese female sex workers in Hong Kong . Journal of sex & marital therapy . 2007 ; 33 ( 1 ): p. 19 – 29 . OpenUrl PubMed 24. ↵ Lim MS , Zhang XD , Kennedy , Li , Yang Y , Li L , et al. Sexual and Reproductive Health Knowledge, Contraception Uptake, and Factors Associated with Unmet Need for Modern Contraception among Adolescent Female Sex Workers in China . PLoS ONE . 2015 ; 10 ( 1 ): p. 1 – 17 . OpenUrl CrossRef PubMed 25. Sullivan, Guédou, Batona, Kintin, Béhanzin, Avery , et al. Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin . BMC Women’s Health . 2020 ; 20 ( 248 ): p. 1 – 14 . OpenUrl CrossRef PubMed 26. ↵ Ward H H , Pallecaros A , Green A , Day S . Health issues associated with increasing use of “crack” cocaine among female sex workers in London . Sexually Transmission Infections . 2000 ; 76 ( 4 ): p. 292 – 298 . OpenUrl 27. ↵ WHO . Selected practice recommendations for contraceptive use. 3rd ed. Geneva: Department of Reproductive Health and Research, World Health Organization ; 2016 . 28. ↵ WHO . World Health Organization . [Online].; 2021 [cited 2022 October 18. Available from: https://www.who.int/news-room/fact-sheets/detail/emergency-contraception . 29. ↵ Tricco AC , Lillie , Zarin , O’Brien K , Colquhoun , Levac D , et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation . Annals of Internal Medicine . 2018 ; 169 ( 7 ). 30. ↵ Bukenya JN , Wanyenze RK , Barrett G , Hall J , Makumbi F , Guwatudde D . Contraceptive use, prevalence and predictors of pregnancy planning among female sex workers in Uganda: a cross sectional study . BMC Pregnancy and Childbirth . 2019 ; 19 ( 1 ). 31. ↵ Schwartz S , Papworth E , Thiam-Niangoin M , Abo K , Drame F , Diouf D , et al. An urgent need for integration of family planning services into HIV care: the high burden of unplanned pregnancy, termination of pregnancy, and limited contraception use among female sex workers in Côte d’Ivoire . Journal of Acquired Immune Deficiency Syndromes . 2015 ; 68 ( 2 ): p. S91 – S98 . OpenUrl CrossRef PubMed 32. ↵ Sibanda E , Shapiro A , Mathers B , Verster A , Baggaley R , Gaffield ME , et al. Values and preferences of contraceptive methods: a mixed-methods study among sex workers from diverse settings . Sex Reprod Health Matters. Sexual and Reproductive Health Matters . 2021 ; 29 ( 1 ): p. 314 – 335 . OpenUrl 33. ↵ Misganaw AC , Worku YA . Assessment of sexual violence among street females in Bahir-Dar town, North West Ethiopia: a mixed method study . BMC Public Health . 2013 ; 13 ( 825 ): p. 1 – 7 . OpenUrl CrossRef PubMed 34. ↵ Weldegebreal R , Melaku YA , Alemayehu M , Gebrehiwot TG . Unintended pregnancy among female sex workers in Mekelle city, northern Ethiopia: a cross-sectional study . BMC Public Health . 2015 ; 15 ( 40 ). 35. ↵ Lafort Y , Greener R , Roy A , Greener L , Ombidi W , Lessit F , et al. Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa . Reproductive Health . 2017 ; 14 ( 13 ). 36. ↵ Ochonye BB , Abiodun PO , Sanni F , Tewobola O , Alamu T , Ogbonna N . Grassroots sexual and reproductive rights interventions on sexual risk behavior among female sex workers in Nigeria . MGM Journal of Medical Sciences . 2021 ; 8 ( 3 ): p. 1 – 10 . OpenUrl 37. ↵ Zhang X , Kennedy E , Temmerman M , Li Y , Zhang WH , Luchters S. High rates of abortion and low levels of contraceptive use among adolescent female sex workers in Kunming, China: a cross-sectional analysis . The European Journal of Contraception and Reproductive Health Care . 2014 ; 2014 ( 1 ): p. 1 – 11 . OpenUrl 38. ↵ Bowring AL , Schwartz S , Lyons C , Rao A , Olawore O , Njindam IM , et al. Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study . Global Health: Science and Practice . 2020 ; 8 ( 1 ): p. 82 – 99 . OpenUrl 39. ↵ Qu S , Liu W , Choi K , Li R , Jiang D , Zhou, et al. The Potential for Rapid Sexual Transmission of HIV in China: Sexually Transmitted Diseases and Condom Failure Highly Prevalent Among Female Sex Workers . AIDS and Behavior . 2002 ; 6 ( 1 ): p. 267 – 275 . OpenUrl CrossRef 40. Wariso F , Ayalew J , Barba A , Bedassa BB , Ebo GG , Tura JB , et al. Determinants of sexually transmitted infections among female sex workers in Ethiopia: a count regression model approach . Frontiers in Public Health . 2023 . 41. Amogne MD , Balcha TT , Agardh A . Prevalence and correlates of physical violence and rape among female sex workers in Ethiopia: a cross-sectional study with respondent-driven sampling from 11 major towns . BMJ Open . 2019 ; 9 ( 7 ): p. 1 – 11 . OpenUrl Abstract / FREE Full Text 42. Choi SY , Chen KL , Jiang ZQ . Client-perpetuated violence and condom failure among female sex workers in southwestern China . Sexually transmitted diseases . 2008 ; 35 ( 2 ): p. 141 – 146 . OpenUrl CrossRef PubMed Web of Science 43. ↵ Apostolidou, Triantafyllidou, Papadaki, Aslanis, Manolopo, Bekiaris, et al. Prevalence of Non-Consensual Condom Removal (Stealthing) in Female Sex Work and Its Association with Perceived Discrimination in Athens, Greece . Psychology . 2023 ; 14 ( 9 ). 44. ↵ Twizelimana D , Muula AS . Actions taken by female sex workers (FSWs) after condom failure in semi urban Blantyre , Malawi . 20 , 273 ( 2020 ). . BMC Women’s Health. 2020; 20(273): p. 1-7. OpenUrl 45. ↵ WHO . Understanding and addressing violence against women . ; 2012 . 46. Patel SK , Ganju D , Prabhakar P , Adhikary R . Relationship between mobility, violence and major depression among female sex workers: a cross-sectional study in southern India . BMJ Open . 2016 ; 6 ( 9 ): p. 1 – 8 . OpenUrl CrossRef 47. Jewkes R , Otwombe K , Dunkle K , Milovanovic M , Hlongwane K , Jaffe M , et al. Sexual IPV and non-partner rape of female sex workers: Findings of a cross-sectional community-centric national study in South Africa . SSM - Mental Health . 2021 ; 1 ( 1 ): p. 1 – 9 . OpenUrl 48. Shannon K , Kerr T , Strathdee SA , Shoveller J , Montaner JS , Tyndall MW . Prevalence and structural correlates of gender based violence among a prospective cohort of female sex workers . BMJ . 2009 ; 339 ( 1 ): p. 1 – 8 . OpenUrl CrossRef 49. Schwitters A , Swaminathan M , Serwadda D , Muyonga M , Ray W , Benech , I , et al. Prevalence of Rape and Client-Initiated Gender-Based Violence Among Female Sex Workers: Kampala , Uganda , 2012 . AIDS and Behavior. 2015; 19(1): p. 68-76. 50. ↵ Suranga MSS , Rajakaruna,, Dewasurendra, Sharma, Das . Unveiling reproductive choices: Knowledge and practices of emergency contraceptive pills among the female factory workers in Sri Lanka . Sexual & Reproductive Healthcare . 2024 ; 39 ( 1 ). 51. ↵ Macleod CI , Reynolds JH , Delate R . Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception , Pregnancy and Abortion . 2022 May 11; 43 : 1604376 . doi. Public Health Review. 2022; 11(43): p. 1-19. 52. ↵ Ippoliti NB , Nanda G , Wilcher R . Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence . Stud Fam Plann. Study of Family Planning . 2017 ; 48 ( 2 ): p. 121 – 151 . OpenUrl 53. ↵ Platt L , Grenfell P , Meiksin R , Elmes J , Sherman SG , Sanders T , et al. Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies . PLOS Medicine . 2018 ; 15 ( 2 ). 54. ↵ Harcourt C , O’Connor J , Egger S , Fairley CK , Wand H , Chen MY , et al. Harcourt C , O’Connor J , Egger S , Fairley CK , Wand H , Chen MY , Marshall L , Kaldor JM , Donovan B. The decriminalization of prostitution is associated with better coverage of health promotion programs for sex workers . Aust N Z J Public Health . 2010 Oct ; 34 ( 5 ). Australian and New Zealand Journal of Public Health. 2010; 34(5): p. 482 – 486 . OpenUrl CrossRef PubMed 55. Wahed T , Zaman S , Huda F , Jiayu L , Sultana S , Alam A , et al. A narrative review of the literature on the reproductive health of female sex workers having age below twenty years . Bangladesh Journal of Medical Science . 2020 ; 19 ( 1 ): p. 17 – 31 . OpenUrl 56. Lau J , Zhou H , Su X , Feng TJ , Hong FC , Tsui HY , et al. Condoms Used But Sex Not Well Protected . AIDS and behavior . 2014 ; 18 ( 10 ): p. 1934 – 1944 . OpenUrl PubMed View the discussion thread. Back to top Previous Next Posted April 03, 2025. Download PDF Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Knowledge and Practice of Emergency Contraception among Female Sex Workers: A Global Scoping Review Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Knowledge and Practice of Emergency Contraception among Female Sex Workers: A Global Scoping Review M. Suchira S Suranga , K. Karunathilake , W. Indralal De Silva medRxiv 2025.04.01.25325048; doi: https://doi.org/10.1101/2025.04.01.25325048 Share This Article: Copy Citation Tools Knowledge and Practice of Emergency Contraception among Female Sex Workers: A Global Scoping Review M. Suchira S Suranga , K. Karunathilake , W. Indralal De Silva medRxiv 2025.04.01.25325048; doi: https://doi.org/10.1101/2025.04.01.25325048 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Public and Global Health Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (297) Cardiovascular Medicine (4420) Dentistry and Oral Medicine (443) Dermatology (381) Emergency Medicine (606) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1507) Epidemiology (15212) Forensic Medicine (30) Gastroenterology (1120) Genetic and Genomic Medicine (6581) Geriatric Medicine (667) Health Economics (996) Health Informatics (4519) Health Policy (1366) Health Systems and Quality Improvement (1611) Hematology (538) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15906) Intensive Care and Critical Care Medicine (1103) Medical Education (620) Medical Ethics (144) Nephrology (667) Neurology (6580) Nursing (345) Nutrition (998) Obstetrics and Gynecology (1141) Occupational and Environmental Health (956) Oncology (3323) Ophthalmology (970) Orthopedics (369) Otolaryngology (420) Pain Medicine (435) Palliative Medicine (129) Pathology (663) Pediatrics (1689) Pharmacology and Therapeutics (691) Primary Care Research (710) Psychiatry and Clinical Psychology (5429) Public and Global Health (9212) Radiology and Imaging (2192) Rehabilitation Medicine and Physical Therapy (1368) Respiratory Medicine (1194) Rheumatology (593) Sexual and Reproductive Health (709) Sports Medicine (529) Surgery (709) Toxicology (99) Transplantation (288) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9fefe78a2d59dfa9',t:'MTc3OTMyNzk1NQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();