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Introduction: Female sex workers (FSWs) psychological health has become a significant issue that affects public health in most low- and middle-income countries (LMICs). Women engaged in prostitution are at heightened risk of mental health challenges, including depression, anxiety, post-traumatic stress disorder (PTSD), and substance abuse. These are often worsened by stigma, social isolation, discrimination, fear of seeking help, poverty, low levels of education, exposure to violence, drug and alcohol use, and HIV infection. This study aimed at assessing the mental health status of adult women (aged 18-49) engaged in prostitution in Livingstone District of Zambia. Material and Methods: Moreover, primary data for this study were collected from respondents using a researcher-administered structured questionnaire consisting of closed-ended questions. The questionnaire was reviewed by the researcher’s supervisor to ensure content validity, and the researcher underwent training in cultural sensitivity and trauma-informed approaches to ensure respectful engagement with participants. A pilot study was conducted with a small group of women engaged in prostitution from selected brothels, streets, bars, and lodges in Livingstone District to evaluate the clarity, reliability, and consistency of the data collection instrument. To minimize the risk of selection bias, all streets, brothels, bars, and lodges that participated in the pilot study within Livingstone district were excluded from the main study sample. Cronbach’s alpha was used to assess the internal consistency reliability of the questionnaire items related to mental health. Results: The study found that most respondents, 61 (59.8%), were aged between 21 and 30 years. In addition, 79 (77.5%) belonged to the middle class, while 74 (72.5%) were single and 83 (81.4%) were unemployed. The study also found that the majority of study participants involved in prostitution, 96 (94.1%), were diagnosed with mental health disorders, while only 6 (5.9%) were not. Marital status (p = 0.003), level of education (p = 0.001), social class (p = 0.009), occupation (p = 0.006), and age (p = 0.004) were found to be significantly correlated with the prevalence of mental health disorders among adult women aged 18–49 engaged in prostitution in the Livingstone District of Zambia. Religion was not significantly associated with mental health disorder prevalence (p = 0.200). These findings suggest that socio-economic and demographic characteristics play an important role in shaping mental health outcomes in this vulnerable population. The study also revealed that the vast majority of respondents 83 (81.4%) were unemployed with living conditions reported as mostly adequate 92 (90.2%). Despite extreme workloads, with more than half respondents working over 60 hours per week, all participants 102 (100%) lacked access to healthcare services. The study also found that more than half of the women (54; 52.9%) reported experiencing physical abuse, while 22 (21.6%) experienced emotional abuse, 16 (15.7%) experienced sexual abuse, and 60 (58.8%) reported social isolation. Most respondents coped with stress primarily by talking to friends or family (75.5%), while fewer relied on substance use (13.7%), recreational activities (5.9%), or physical exercise (3.9%). Stigma was identified as the main barrier to mental health service utilization (75.5%), compared to lack of awareness (23.5%) and financial constraints (1.0%). The majority (89.2%) perceived their coping mechanisms as effective, and nearly all (98.0%) had considered leaving prostitution to improve their mental health status, though most (96.1%) remained due to financial dependence. Despite widespread access to community mental health services (97.1%), actual utilization was very low, with only 15.7% ever accessing support. Conclusion: All in all, the study highlights the vulnerability of women in prostitution, most of whom are young, unemployed, and living under precarious conditions. High rates of mental health disorders, extreme workloads, and widespread experiences of violence and social isolation accentuate the severity of their challenges. Although many rely on informal coping strategies and perceive them as effective against stress, stigma and lack of service utilization leave them excluded from formal mental health support programs. Financial dependence remains the primary reason for continued involvement in prostitution, despite nearly all participants expressing a desire to leave. The author recommends that, strengthening legal frameworks against violence, improving psychosocial support, creating sustainable livelihood opportunities, and expanding accessible, stigma-free healthcare with targeted interventions are critical to safeguarding the rights, dignity, and well-being of this marginalized population while addressing both mental health and socioeconomic barriers.