Prevalence of Non-Consensual Condom Removal (Stealthing) in Female Sex Work and Its Association with Perceived Discrimination in Athens, Greece ()
1. Introduction
Non-consensual condom removal (NCCR), also known as stealthing, is a form of sexual violence (SV) (Alam & Alldred, 2021; Tarzia et al., 2020) , and is defined as the intentional condom removal or destruction during sexual intercourse without consent (Bonar et al., 2021; Chesser & Zahra, 2019; Latimer et al., 2018; Shapiro, 2021) . It takes place without the other partner’s knowledge and automatically renders sexual intercourse non-consensual and unprotected (Alam & Alldred, 2021; Brodsky, 2017; Latimer et al., 2018; Shapiro, 2021) . Stealthing endangers the partner’s sexual health, as it increases the risk of sexually transmitted infections (STIs), and unwanted pregnancy (Chesser & Zahra, 2019; Latimer et al., 2018) . On an emotional level, stealthing survivors experience feeling violated, as well as guilt, shame, and self-recrimination (Brodsky, 2017; Shapiro, 2021) . Moreover, it is commonly associated with substance use (Bonar et al., 2021) . Bocheński and Żebracki (2021) assert that experiencing stealthing has much in common with being a rape victim.
Overall, instances of SV and gender-based violence (GBV), two worldwide phenomena with severe repercussions for survivors’ physical and mental health (World Health Organization, 2013) , seem to be more frequently affecting women and other minority groups (Bacchus et al., 2018; Davis et al., 2023; Deering et al., 2013; Evens et al., 2019; Lang et al., 2013) . That occurs due to gender inequalities which are sustained by and, at the same time, reinforce patriarchal stereotypes and discrimination, as well as male dominance, and seem to normalize abusive behaviors toward women and minorities (Decker et al., 2020; Logie et al., 2020; Poulios, 2018; Wirtz et al., 2015) . Regarding stealthing in particular, Bonar et al. (2021) found that 18.9% of women have been victims of stealthing, with 2.5% having been exposed to this form of abuse three to five times.
Female sex workers (FSWs) are a particularly vulnerable group in this regard, since they are both women and marginalized because of their work. According to a recent Australian study, FSWs are three times more likely to suffer stealthing than other women (Latimer et al., 2018) . Male clients often tend to take advantage of the unequal power dynamics and stigma, making it difficult for FSWs to negotiate and establish their workplace boundaries. FSWs usually report that clients resist or refuse to use condoms during sexual services and threaten them with violence for unprotected sex (Decker et al., 2020; Deering et al., 2013; Rhodes et al., 2008; Tounkara et al., 2014) .
Other risks FSWs are exposed to due to stigma and discrimination against sex work (Armstrong, 2019; Benoit et al., 2018; Grittner & Walsh, 2020) include harassment, violence, and mistreatment from clients and the police (Decker et al., 2015, 2020) , unjustified arrests (Decker et al., 2020) and difficulty in accessing healthcare or welfare services (Suresh et al., 2009) . FSWs’ psychological vulnerability is further increased by sex work criminalization (Beattie et al., 2020; Platt et al., 2018; Wong et al., 2011) . In fact, research shows that FSWs often present symptoms of depression (Platt et al., 2018) , post-traumatic stress disorder (Jewkes et al., 2023) , anxiety, and psychological distress (Deering et al., 2013) .
To the best of our knowledge, no research on stealthing has been conducted in Greece, whether in the general population or within vulnerable social groups like sex workers. It is worth noting that in Greece, much like France (Paillet, 2020) , stealthing is not legally acknowledged as sexual assault, which renders victims vulnerable in accessing support services (Davis et al., 2023) . Additionally, the country’s legal framework adopts the German-Dutch model of sex work, which classifies sex work as partially criminalized. However, the law’s requirements are so stringent that they are all but impossible to uphold, rendering sex work practically illegal (Jahnsen & Wagenaar, 2019) . This exacerbates the stigma that sex workers face and renders them effectively invisible, hampering their ability to access legal protection and thereby increasing their likelihood of being assaulted by stealthing or other forms of GBV and SV.
The present study aims to investigate the prevalence of stealthing in FSWs in Athens and its association with the participants’ psychosocial health. Specifically, the study examines the association between stealthing and FSWs' psychological distress and perceived discrimination. To the limit of our knowledge, this is the first study on stealthing conducted in the Greek population and the first to quantitatively investigate its association with perceived discrimination.
2. Methodology
2.1. Procedure & Participants
The participants were recruited during their visit to Red Umbrella Athens, a community center for sex workers in Athens. Red Umbrella Athens provides HIV, HBV, HCV and syphilis testing, as well as psychosocial care, legal and sexual health counseling and empowerment activities. A trained staff member asked all consecutive cis and trans female sex workers that visited the center during February and March 2022 to participate, having informed them about the study’s goals both verbally and in writing. The exclusion criteria for this study were participants under the age of 18 years, individuals who did not understand or read Greek, and those currently intoxicated or under the influence of drugs. Those who met the criteria and agreed to participate signed a consent form and filled out the questionnaire on their own in a private designated area. Participation in the study was voluntary, anonymous, and without compensation. The research meets the Helsinki Declaration guidelines and its protocol was approved by the bioethics committee of “Attikon” University Hospital (code ΔΠΠΚ, ΕΒΔ43/24-01-2022).
A total of 71 cis (80.3%, n = 57) and trans (19.7%, n = 14) female sex workers provided informed consent and valid answers to the questionnaire. A percentage of 43.7 (n = 31) were Greek, while 56.4% (n = 40), were migrants and refugees, from Russian-speaking nations, (Russia, Belarus, Kazakhstan, Ukraine, Georgia, and Moldova, 25.4%, n = 18), the Balkans, (Serbia, Bulgaria, Romania and Albania, 25.4%, n = 18), or other countries (5.6%, n = 4). The mean age of participants was 41.1 years (Mdn = 42, SD = 13), ranging from 18 to 70. 40.8% (n = 29) of the sample reported being in a committed relationship with a mean length of 81 months, 32.4% (n = 23) being exclusive, and 26.8% (n =19) living together.
Most participants (73.2%, n = 52) work full-time, while the rest (26.8%, n = 19) work part-time or occasionally. In total, 78.9% (n = 56) reported that they only had sex with men, while the rest (21.1%, n = 15) reported having sex with men, women and other genders. Finally, the average number of male sexual partners in the past six months was 1220.6 with a median of 540 (SD = 1524.5).
2.2. Measures
The research was conducted with the use of a self-administered questionnaire.
We identified stealthing incidents in line with the approach of Latimer et al. (2018) . Participants were asked whether they had had sex during which the condom was removed without their consent and (1) the intercourse stopped, (2) the removal was realized afterwards, (3) the intercourse continued unwillingly on their behalf or (4) the condom was never put on, despite being requested. On this scale (1 - 4) Latimer et al. (2018) deemed (4) to be the most and (1) the least severe. A positive answer to any of these items was deemed as a stealthing incident. Participants who reported having experienced more than one stealthing incident were asked to base their subsequent responses on the incident with the highest of the numbers above (1 to 4). The questionnaire assessed the type and length of relationship with the sexual partner, way of meeting, and substance and alcohol use of both people involved in the stealthing incident. Participants were also asked about the effects of the incident, whether they had discussed it with the sexual partner with whom stealthing occurred, if they had talked about it with family and friends or if they had reported it to the police. The study also included demographic, epidemiological and violence-related questions, namely age, gender identity, committed relationship status and details, sex work related questions, SDU, sexualized alcohol use and sexual coercion in a committed relationship.
Psychosocial health was measured using the translated 12-item General Health Questionnaire adapted in Greek by Moutzoukis et al. (1990) . It assesses overall psychological distress. The more severe the participants’ mental health issues are, the higher their final score. Perceived discrimination was assessed using the back-translated Everyday Discrimination Scale (Williams et al., 2008) . The more intense the discrimination that participants perceive themselves to be facing, the higher their final score. It also assesses the main reasons that participants perceive discrimination against them to occur (ancestry and ethnicity, gender, age, religion, body height and weight, color of skin, gender expression, sexual orientation, education or income level, physical disability being a sex worker).
2.3. Statistical Analyses
We measured absolute and relevant frequencies and descriptives of demographic and sex work related variables for the total sample and frequencies of stealthing among participants that have experienced stealthing. Missing values were examined and assessed as not systematically related to the data. We then examined significant associations between demographic, epidemiological, sex work and violence related variables and stealthing experience using chi-square tests in the case of nominal variables and Mann-Whitney U non-parametric tests in the case of continuous variables, due to unbalanced sample sizes in two stealthing conditions (yes or no). Non-parametric Mann-Whitney tests and Student’s t-tests gave similar results, despite violations of normality, so we present only the latter for parsimony reasons. After conducting multiple regression analysis and controlling for potential confounding variables, specifically age and gender identity, we found that the association between the variables that presented statistically significant associations with stealthing remained significant (p < .05). This indicates that age and gender identity does not appear to confound the observed relationship between discrimination and stealthing, strengthening the validity of our findings. The homogeneity of cis and trans female sex workers in relation to stealthing experiences was verified using chi-square analyses.
The threshold for statistical significance was defined at .05. Analyses were conducted using the IBM SPSS Statistics software, version 25.
3. Results
3.1. Stealthing Descriptives
In total, 63.4% (n = 45) of cis and trans female sex workers have experienced stealthing, of those 53.5% (n = 38) reported stopping sexual intercourse after they realized that the condom had been removed, 26.8% (n = 19) realized that the condom had been removed afterwards, while 15.5% (n = 11) continued the act unwillingly after realization. Finally, 21.1% reported that the sexual partner never put on the condom despite the participants requesting that they should.
As can be seen in Table 1, among the stealthed participants, 38.6% reported they have experienced stealthing more than once (n =17), 88.6% report that the sexual partner was a client (n =39) and 79.5% report that the relationship with them lasted less than a day (n = 35). The stealthing incident in most cases was discussed with the sexual partner (77.8%, n = 35) and the most common consequences included negative emotional and psychological effects (51.1%, n = 23), and verbal or physical fights between the involved parties (46.6%, n = 21).
Additionally, in half of the stealthing incidents reported the perpetrator had
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Table 1. Stealthing situational variables as reported by participants that have experienced stealthing (n = 45).
aParticipants could select multiple responses to the questions, therefore percentages do not sum to 100. Percentages represent the proportion of participants who have reported the event.
not used illegal psychoactive substances (53.3%, n = 24). On the other hand, the majority of victims were sober during the incident (86.7%, n = 39). Furthermore, a third of the cases reported involve alcohol use by the perpetrator (33.3%, n = 15). All female sex workers consider stealthing an immoral act (100%, n = 45), almost all of them consider it illegal (97.8%, n = 44), 75.6% (n = 34) consider it sexual abuse and 66.7% (n = 30) think it is possible in every sexual encounter.
Moreover, sex workers avoided discussing the stealthing incident with any family members (88.9%, n = 40), mostly because the latter were unaware of participants’ involvement in the sex industry (31.1%, n = 14), or because participants accepted stealthing as a work-related hazard (17.8%, n = 8). As far as official reporting goes, 97.8% (n = 44) of the participants that experienced stealthing did not involve the police, as around half of them reported being afraid of getting into trouble (51.1%, n = 23), and thinking that the police would not do anything (48.9%, n = 22) (Table 2).
3.2. Demographics and Experiences of Violence Associated with Stealthing
Regarding demographic and epidemiological variables, Table 3 shows that no
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Table 2. Reports of stealthing incident by participants that have experienced stealthing (n = 45).
aParticipants could select multiple responses to the questions, therefore percentages do not sum to 100. Percentages represent the proportion of participants who have reported the event.
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Table 3. Demographics psychological distress, perceived discrimination, and epidemiological variables and its associations with stealthing in cis and trans female sex workers (n = 71).
Notes. 1In the past six months. 2In the past 12 months. 3SDU = Sexualized drug use in the past 12 months. 4In their lifetime.
significant relationships were found between stealthing experience and age t(69) = .97, p = .336, ethnicity x2 (1) = .031, p = .861 as well as gender identity x2 (1) = 1.345, p = .246. However, the number of male sexual partners was significantly higher among participants that reported stealthing incidents t(60.23) = −3.65, p = .001. Additionally, no statistically significant relationships were found between being the victim of a stealthing incident and either alcohol x2 (1) = .053, p = .817 or substance use x2 (1) = 1.802, p = .179 in a sexual context over the past 12 months. Finally, the experience of sexual coercion in a committed relationship was significantly more frequent among participants that reported stealthing experiences x2 (1) = 4.559, p = .033.
3.3. Discrimination and Psychological Health and Associations with Stealthing
As shown in Table 3, the perceived discrimination was significantly differentiated in relation to stealthing experiences t(69) = −2.08, p = .042. Female sex workers that have experienced stealthing reported higher perceived discrimination (M = 1.58, SD = .73) than those who have no such experiences (M = 1.16, SD = .87). The main reason for perceived discrimination was sex work, reported by 32.4% of the sample, followed by gender (28.2%) and gender identity (19.7%). Being from a country of origin other than Greece was mentioned by 9.9% of the sample and the rest 9.8% report age, height, weight and socioeconomic status as the reason for perceived discrimination. Furthermore, the psychological health of female sex workers was also significantly differentiated between stealthing conditions t(69) = −2.08, p = .042. Specifically, participants that had experienced stealthing reported higher psychological distress (M = 2.31, SD = .46) than the rest (M = 2.09, SD = .40).
4. Discussion
Our findings indicate that the FSW population is particularly vulnerable to stealthing, as almost two-thirds of the sample have been stealthed, of which the majority reported the client as the perpetrator. In most incidents, FSWs reported that they had been sober and only some of the perpetrators had used alcohol. Additionally, participants who had experienced stealthing reported higher perceived discrimination, mostly related to sex work. Finally, it appears that while FSWs experienced instances of stealthing as a violation and stated that these events had had emotional and psychological consequences, they did not report them to authorities or discuss them with family.
In accordance with Latimer et al.’s (2018) findings, FSWs reported high rates of stealthing incidents. Additionally, the present study further strengthened the validity of the association between sex work and stealthing, as FSWs also reported that the majority of stealthing incidents (88.6%) were work related, with the client being the perpetrator. The severity of the stealthing problem in the sex work industry becomes more apparent when we consider that around one-third of FSWs (38.6%) have experienced stealthing more than once. Based on our findings, we can assume that unequal gender dynamics (Decker et al., 2020; Logie et al., 2020; Wirtz et al., 2015) , lack of legal protection and discrimination (Benoit et al., 2018) , and the high number of sexual partners (Latimer et al., 2018) contribute to the prevalence of stealthing in FSWs.
The association between stealthing and perceived discrimination also yielded interesting results. FSWs who have experienced discrimination in everyday life have also reported stealthing incidents. According to participants, the discrimination is primarily due to sex work itself. Perceived discrimination and social marginalization seem to enhance the internalized stigma and feelings of shame and guilt about the sex work identity (Benoit et al., 2018; Wong et al., 2011) , thereby exacerbating participants’ vulnerability. Under this lens, negotiating sex work services and boundaries (Lang et al., 2013; Wirtz et al., 2015) becomes an even harder and more onerous process, which can include self-recrimination and a feeling of inadequacy.
Another reason for discrimination mentioned by the participants was gender and gender identity. As mentioned above, gender discrimination increases the vulnerability to abusive behaviors due to the patriarchal ideals that still dominate the societal status quo (Decker et al., 2020; Logie et al., 2020) . This finding is also strengthened by the fact that a number of FSWs who described a stealthing incident also reported having experienced SV within a committed relationship. Previous violent traumatic experiences in life may act as a barrier to negotiating personal boundaries and condom use, due to fear of another violent situation (Tounkara et al., 2014) . Regarding gender identity, it is worth highlighting that all trans FSWs in our sample reported that they had been victims of stealthing, a finding that is congruent with the vulnerability of the trans population pointed out by relevant research literature (Evens et al., 2019) . However, it needs to be noted that the very small population sample in the present study makes it impossible to draw more general conclusions regarding these findings.
The effects of discrimination and internalized stigma are also made clear by the fact that very few participants notified family members of the assault incidents, fearing the possible repercussions of informing the family of sex work, social stigma, and fears that the abuse would be dismissed due to prejudice regarding their the stereotypes for sex work. As sex work is criminalized in Greece, and stealthing is not recognized as a sexual assault, participants also feared legal trouble (Decker et al., 2020) , which is why they overwhelmingly did not go to the police.
Regarding substance use during stealthing incidents, contrary to previous reserach in general population (Bonar et al., 2021) ; our study revealed that the majority of FSWs had not used any substance. The high rate of sobriety among the participants may explain the fact that the majority of them stopped the sexual intercourse when they realised the assault. Certainly, drug use during sex does have a significant impact on how feasible it is for FSWs to set and maintain safety boundaries, while at the same time raising certain concerns about consent. Conversely, sobriety may allow them to recognise the boundary violation and react against it, since a number of the participants report fighting with the perpetrators when they realized the abuse. As for the substance use by the perpetrators, we found that a high percentage was rather sober while engaging in stealthing, which delineates the conscious intent of the abusive behavior.
Lastly, our findings show that FSWs who have been stealthing victims face more mental health challenges (Latimer et al., 2018) than those who have no such experiences. In general, FSWs are already facing psycho-emotional challenges (Beattie et al., 2020; Platt et al., 2018) due to stigma and discrimination and are, therefore, more exposed to abusive behaviors, which can negatively impact their mental health even further. The frequent exposure to harassment and violent behaviors, such as stealthing incidents, can trigger feelings of frustration, which can affect their psychosocial everyday life. In addition, the sense of bodily violation (Brodsky, 2017; Tarzia et al., 2020) and the dangers involved in stealthing may reinforce feelings of shame and self-deprecation (Chesser & Zahra, 2019) that are linked to sex work itself.
5. Limitations and Implications for Further Research
This study has certain limitations. Taking into consideration that the FSW population is not easily accessible, due to stigma associated with sex work, the number of participants is limited. Additionally, participants live and work exclusively in Athens, on the street or in brothels, and are beneficiaries of the Red Umbrella Athens prevention and empowerment community center. For these reasons, our findings are not widely generalizable. Rather, they constitute a preliminary mapping out of the phenomenon among female sex workers in Greece.
In further research it would be useful to have a larger sample of participants, including an adequate representation of vulnerable social groups, such as transgender SWs and gay, bi and other men who have sex with men. Moreover, it might be advisable to use additional means to approach participants and collect data, in order to include people in other kinds of sex work, such as those working through ads or online, as well as sex workers from different parts of the country.
6. Conclusion
Our findings align with existing literature on stealthing, contributing to the growing body of evidence that recognizes it as a form of sexual assault with profound implications for the physical and mental well-being of the victims (Tarzia et al., 2020) . Stealthing’s prevalence in women and other marginalised populations, such as sex workers (Decker et al., 2020; Latimer et al., 2018; Logie et al., 2020) calls for strict policy measures. However, even if stealthing gets legally acknowledged as assault, sex workers will still not be able to protect their rights, seek justice and hold the perpetrators accountable for their actions as long as their profession remains criminalized. In order to achieve sustainable comprehensive policies, there is an urgent need not only to decriminalize sex work, as suggested by organizations like Amnesty International, World Health Organization, and Human Rights Watch (Wodda & Bhat, 2020) , but also for a broader, more inclusive dialogue that incorporates intersectional perspectives and meaningfully engages the sex worker community.
Lastly, organizations that work with, and support minority groups, such as SWs, need to be properly trained to address SV, support survivors and work towards prevention and advocacy. For this reason, it is imperative that they adopt inclusive practices, taking into account the intersecting identities of their beneficiaries and the challenges they face due to discrimination and stigma, with the primary purpose of promoting their health and well-being.