Abstract
INTRODUCTION: Sex workers are exposed to high levels of mental health risk. Yet, the psychological effects of self-stigmatization in legalized sex work contexts remain underexplored. This study examines how different dimensions of self-stigma influence mental health outcomes among female sex workers (FSWs) in Germany, where sex work is legalized and regulated. METHODS: A cross-sectional study was conducted with 397 FSWs recruited across diverse work settings in Germany between August 2022 and October 2024. Mental health conditions were assessed using the Mini-DIPS Open Access structured interview. Self-stigmatization was measured via the Paradox of Self-Stigmatization Scale (PaSS-24), which captures three dimensions: stereotype endorsement, non-disclosure, and righteous anger. Logistic regression analyses were used to examine associations between self-stigma and four psychiatric outcomes: affective disorders, anxiety disorders, trauma-related disorders, and substance use disorders, adjusting for demographic and occupational covariates. RESULTS: A high prevalence of mental health disorders was observed among participants, reflecting the categories assessed in this study (affective, anxiety, trauma-related, and substance use disorders). Emotional and behavioral dimensions of self-stigmatization, particularly concealment and emotional reactivity, showed associations with certain psychiatric outcomes. In contrast, cognitive endorsement of stereotypes showed no consistent links to mental health status in this sample. DISCUSSION: Findings support the "Paradox of Self-Stigma" model: FSWs cognitively reject negative stereotypes yet exhibit strong emotional and behavioral responses that heighten psychological distress. Righteous anger and concealment may reflect unresolved trauma rather than resilience. Interventions should address emotional stigma responses, promote safer work environments, and support disclosure in trusted relationships. This study highlights the need for context-sensitive, multidimensional strategies to reduce stigma-related mental health burdens among sex workers in legalized systems.