Written submission from the Faculty of Public Health and Policy,
London School of Hygiene and Tropical Medicine (PTN0069)
What, if any, are the harms associated with buying and selling sex? Who is affected? How?
Sex workers face multiple, inter-dependent health risks including violence, HIV and sexually transmitted infections (STI), alcohol and drug-related harms, emotional ill-health and reduced access to care.1 In the UK, up to 64% of female sex workers report violence at work2,3, up to 46% report anxiety or depression and up to 30% currently inject drugs.1 Among sex workers attending genitourinary medicine (GUM) clinics, prevalence of chlamydia, gonorrhoea and HIV is 10%, 3% and 0.2%, respectively, for women and 25%, 17% and 4% for men.4,5 No such estimates are available for transgender sex workers, but data from the Netherlands suggest a high prevalence of HIV (18%).6 These figures reflect significant health disparities: women who sell sex are 12 times more likely to be murdered than women their age7, and male and female sex workers have 1-3 times higher odds of chlamydia and gonorrhoea compared with other GUM clinic attendees. For male sex workers specifically, odds of HIV is 3.4 times higher than for non sex-working men (adjusting for age and sexual identity).4,5
There are also considerable health inequalities within the sex worker population, relating to individual, interpersonal, work environment and community factors, and broader aspects of the structural (e.g. legal, economic) environment.8,9 Women working in street-based sex work, for example, are at far greater risk of violence, HIV, STI, emotional ill-health, and drug and alcohol problems, than women who work indoors.1,2 Two recent systematic reviews demonstrate that, internationally, increased risk of violence and HIV are associated with less education, work environment (outdoor), stigma, lack of access to clinics and peer-led sex worker organisations, being forced into sex work, economic pressures, criminalisation and enforcement-based policing.8,9
How effective are Government policies in tackling this?
In England and Wales, the sale and purchase of sex between consenting adults in private is legal. However, most activities related to sex work including brothel keeping, kerb crawling, advertising sexual services are illegal. Scotland applies the same model as England and Wales, but Northern Ireland changed the law to criminalise the purchase of sex in 2015.
In practice policing varies widely in the UK depending on local resources and attitudes of local authorities and police forces.10 For example, a managed approach is operated in Leeds, which effectively allows sex workers to work without arrest at certain times and in a defined area. A designated sex work liaison officer (SWLO) works in close partnership with sex workers, residents and third sector agencies to facilitate reporting of crimes by sex workers and act as a liaison between the community and women. A network of social support services work to support the health, social and welfare needs of the women. Evaluations of the managed approach report improved access to health and social services for sex workers, improved relationships with the police and better reporting of violence as a result of the SWLO as well. Relationships with local communities have been mixed, with some reports of improved understanding around sex work and fewer complaints about people working but still concerns around litter and some difficulties in relationships between local businesses and sex workers. 11,12 In other places including Nottingham, Suffolk, Tower Hamlets and Swansea, police focus on aggressive enforcement of laws against kerb crawling.13 14,15 National policing guidance emphasises that the starting point for policing should be to ensure that sex workers should not be treated as criminals and the focus of law enforcement should be to improve safety and target those that exploit or cause harm.16
Broadly there are 5 legislative models used internationally to manage, control or regulate sex work: (1) Full criminalisation prohibits all organisational aspects of sex work and selling and buying sex e.g USA; (2) Partial criminalisation is where some aspects of sex work are penalised (e.g., soliciting sex in public for sex workers and/or clients, advertising services, collective working, or involvement of third parties) as applied in the UK; (3) Criminalisation of the purchase, but not the sale, of sex as applied in Canada, Sweden, Norway, Ireland, Northern Ireland; (4) Regulatory models make the sale of sex legal in certain settings (e.g., in licensed brothels or managed zones) or under certain conditions (e.g., mandatory registration or HIV/STI testing) but illegal in other settings or for individuals who do not meet registration requirements or eligibility criteria (e.g., migrants, cis men and trans sex workers, or people living with HIV) as applied in Mexico, Guatemala, Germany as Nevada (USA); (5) Full decriminalisation removes criminal penalties for adult sex work, emphasises enforcing criminal laws prohibiting violence e.g New Zealand
We undertook a systematic review of research (quantitative and qualitative) conducted across different countries, to assess the extent to which, and how, criminalisation affects sex workers’ safety, sexual and emotional health, and access to health and social care services.17 We systematically searched published public health and social science research and identified 86 studies (40 quantitative, 46 qualitative) across 33 countries that reported data directly from people who sell sex and met key methodological quality criteria. We included studies with sex workers of all genders.
We undertook a meta-analysis (pooling results from eligible quantitative studies) to estimate the average effect of experiencing physical/sexual violence, HIV or sexually transmitted infections (STI), and sex without a condom, for sex workers who had experienced repressive policing (arrest, imprisonment, confiscation of condoms or needle/syringes, violence from police, or displacement) compared to those who had not.
Key harms identified
We found that sex workers who had experienced repressive policing were three times as likely to experience incidences of violence (sexual or physical, by any party), twice as likely to have HIV or an STI infection, and 1.5 times as likely to have sex with a client without a condom, compared to those who had not experienced repressive policing. Three studies that examined mental health showed that recent incarceration, arrest, and increased police presence were associated with poorer mental health. Repressive policing was also associated with increased alcohol and other drug use, increased public injecting (linked to skin and soft tissue injuries and infections), and injection in the groin (linked to overdose).
How these harms are produced
Our thematic synthesis of 46 qualitative research papers identified key themes and differences in how criminalisation affects sex workers’ health and safety across different legislative and policing models
This synthesis shows how criminalisation increases vulnerability and health harms through the following pathways:
Firstly, it disrupts sex workers' workspaces and safety strategies. Laws against soliciting and communication in public places for the purposes of sex work, and feared or actual arrest (of sex workers or their clients), meant that sex workers had to rush client screening and negotiations, or conduct these in secluded places. This resulted in greater vulnerability to violence and theft. In indoor settings, laws against brothel-keeping prevented sex workers from working together, and sharing information, for safety, and sometimes restricted availability of condoms.
Secondly it institutionalises violence, coercion and extortion, restricting access to justice. Commonly reported policing practices - including arrest, detention, physical displacement, intimidation, verbal harassment, extortion and sexual services in lieu of arrest or detention, and physical and sexual violence̶ - institutionalised violence against sex workers. Failure of police to act on sex workers’ reports of violence against them, frequently blaming and criminalising them when such reports were made, created environments of impunity where violence, theft and extortion continued, and increased sex workers’ reluctance to report violence or other crimes.
Thirdly, it worsens stigma and inequality. Repressive police practices reinforced existing inequalities and marginalisation, exacerbating disparities within sex working communities. Police targeted specific sex-work settings or populations so often it is the most vulnerable and marginalised who are the most affected including trans women, people of colour, migrants, people who use drugs and people who work outdoors.
Fourthly, it restricts access to health and social care and support. Police crackdowns on sex work venues and outdoor areas disrupted peer networks and displaced sex workers from their usual places of work. This restricted established safety systems and access to outreach services.
The public health evidence supports full decriminalization of sex work, including the avoidance or removal of penalties targeting clients and activities around the organisation of sex work, particularly when you consider this evidence in the light of a human rights framework.18
How does buying and selling sex affect attitudes towards women more widely?
Sex work is a difficult issue to discuss, since the debate around sex work takes place within a context of passionately held moral, ideological and sometimes political view points. As an issue that provokes profound emotions it’s often difficult to talk about in an objective dispassionate way let alone develop and implement practical and effective policy responses. There are some things that everyone can agree on including the fact that improving the health and welfare of people working in the sex industry and communities is our priority. The question we need to ask is what legal and policy environment is going to minimise harms and maximise health and well-being of these populations?
Some people argue that all sex work is itself gendered violence and should be abolished, this is the rationale that underpins the Swedish model that criminalises the purchase of sex. 19 However, the implication that all sex work is ’essentially abusive’ not only disrupts provision of health and support services to sex workers (as seen in Sweden) but fails to recognize the diversity of experience in the sex industry, the complex and varied reasons why people enter sex work, and the possibility that financial reimbursement for sex between adults can be consensual.20 Findings from a recent report summarising community evidence on the effect of 20 years of the Swedish model suggest that the policy reinforces stigma against sex workers. Given the ultimate aim of the policy is to end demand for sex work and as a result the need for sex workers, people think there must be something wrong with someone who decides or has no option but to continue in sex work. This has resulted in entrenched discrimination and exclusion of sex workers, with service access often contingent on sex workers stopping sex work. 21,22
Opponents of decriminalising sex work voice concerns that this model normalises violence and gender inequalities. However, our review shows how criminalisation of sex work (including the sale and purchase of sex, and organisation of sex work) fuels these harms, by restricting sex workers’ access to justice and reinforcing the stigmatisation and marginalisation of women, sexual and gender minorities.
What more could be done?
Legislation must prioritize sex workers’ safety, health, and access to care, welfare, justice and rights, in recognition of the diverse realities of sex work. We reiterate that the public health evidence strongly supports full decriminalization of sex work, including the avoidance or removal of penalties targeting clients.
Changes to sex work laws, alone, are not enough; they must be accompanied by wider political action to tackle stigma, discrimination and exclusion faced by sex workers. This can include laws against discrimination and hate crime, as well as decriminalisation of drug use and inclusive housing, welfare and immigration policies. It also requires commitment to tackling cultures of stigma within institutions and broader society.
Alongside law and institutional reforms, interventions are needed to protect the safety and health of sex workers, including the funding and scale-up of specialist and sex-worker-led services that help address the multiple and diverse health and social care needs of people who sell sex.
Increased access to harm reduction and drug treatment services are also needed, given the overlap between heroin and/or crack use and women working in street-based sex work. Women who inject drugs experience a higher prevalence of HIV, Hepatitis C, skin and soft tissue injury, sexual and physical violence, poor mental health and suicide than their male counterparts, yet gendered power imbalance, stigma and confidentiality concerns mean they are less likely to access needle/syringe programme and opioid substitution therapy. 23 International evidence suggests that services do not consider gendered specific needs and are often tailored towards men. Few drug treatment services address other needs that women face including sexual health, pregnancy or support as a parent, despite evidence to show that pregnancy is a key motivator to entering drug treatment. Unsurprisingly, evidence suggests that women are less likely to remain in opioid substitution treatment and consequently be less effective. A recent outbreak of HIV has also been recorded in Glasgow among people who inject drugs (PWID), with some evidence to suggest risk was higher among women who injected drugs.24 This was one of the largest outbreaks in Western Europe and means we cannot assume that historically low rates of HIV among PWID in the UK (2%) will remain stable.
What local initiatives are you aware of that address these harms? Are they effective? Why?
Sex worker support services have long been recognised as vital to addressing the complex health and social care needs of this marginalised and dynamic population, globally. 25 In the UK, initially set up as sexual health services, they were able to halt early outbreaks of HIV, syphilis and tuberculosis among sex workers 26 and they remain vital in this respect: in 2008, we found that sex workers in London who had been visited by an outreach worker in the past year had a 73% reduced risk of contracting an STI.3
Specialist services also work with local agencies to provide integrated care and case management. They support sex workers who have experienced sexual violence; help them deal with drug and alcohol use, mental health issues, and housing needs and avoid criminalisation (e.g. facilitating access to criminal justice and avoid prison sentences as well as developing relationships with police and sensitising police to sex workers’ needs); and employ multilingual outreach workers in settings where many sex workers are migrants. They also help women who want to leave sex work by findings a way to do so that work for them and is sustainable. Crucially however, this is not the only focus of their work nor a condition of service access. This joined-up approach reflects best practice by combining consideration of the policy environment, community level interventions, and tailored individual responses. 27 Specialist services particularly benefit the most marginalised sex workers, such as migrants and those who are homeless, use drugs, or work outdoors, connecting them to mainstream health and social care. However, given the stigmatised nature of the industry, all sex workers could benefit from such services. Some sex workers are not registered with primary care doctors, and those who are may be reluctant to disclose their profession out of fears over confidentiality and judgment. 28
What, if any, are the challenges for those facing harm in accessing services (for example, healthcare; support services; advice; exit services)? What needs to change?
A growing number of specialist services have faced substantial cuts in recent years, in line with wider cuts to services.29 This has occurred alongside shifts in how services are commissioned, increasingly through local authorities’ violence against women and girls or drugs and community safety strategies rather than public health. Access to services in contingent on promises to exit sex work, with limited services prioritising those who show commitment to exiting, leaving the most marginalised without access to much-needed housing, social services and welfare support and failing to deliver even the most basic harm reduction activities. For example Open Doors a specialist sex worker service that provided individual case managed support to sex workers working in street settings in Newham has been completely cut, despite their longstanding and trusting relationships with women addressing their extreme health and support needs.30
What relevance does the Public Sector Equality Duty have for the way that public authorities?
Findings from our systematic review clearly showed that repressive police practices reinforced existing inequalities and marginalisation. Police targeted specific sex-work settings or populations so often it is the most vulnerable and marginalised who are the most affected, including women who work on the street and/or have drug addictions, women colour and migrants (inclusive of trans women). For this reason, the Public Sector Equality Duty is clearly relevant to the way that sex work is treated by the law.
How does the law currently treat paying for sex? How could law and policy be improved to address harm?
Currently paying for sex is legal but activities around the purchase of sex such as kerb crawling are illegal. We summarise below international evidence that shows how the criminalisation of the purchase of sex reproduces the same harms as the criminalisation of sex work. We note with grave concern changes in policing practices across England and Wales that emphasise enforcement against kerb crawlers, including for example in Swansea, Ipswich, Tower Hamlets and Nottingham. 13 14,15
As highlighted in our systematic review, qualitative evidence shows how criminalization of clients reproduces vulnerabilities experienced by sex workers in the same way as criminalization of sex workers themselves and can further entrench marginalization. In Canada, soliciting is still displaced into more isolated work areas so that clients can avoid the police, which can disrupt support networks and increase the likelihood of exposure to violence, including forced unprotected sex. Concerns about arrest still reduce time for negotiations over services or screening out potentially dangerous clients with the same consequences.31 Evidence from Sweden shows that those people who decide or have no choice but to stay in sex work experience increased marginalization, with sex work seen as inherently dangerous. Constructing sex work as a form of violence, the sex-buyer law has been accompanied by an end of harm reduction interventions for sex workers, with the distribution of condoms perceived to be condoning sex work and, as a consequence, perpetuating violence against women.22 These data are derived from interviews with sex workers, reflecting their lived experiences of the policy and point to harmful unintended consequences, difficult to avoid however carefully implemented.
The public health evidence clearly points to the need to decriminalise sex work, specifically the removal of criminal and administrative penalties used as punitive sanctions against sex workers and their clients.
How effective are different international approaches at addressing any harms associated with buying and selling sex?
As mentioned above, studies highlighted that in Sweden and Canada, criminalisation of clients did not improve access to services nor reduce sex workers’ experiences of violence. Evidence included in our qualitative synthesis clearly shows that criminalisation of clients does not facilitate access to services, nor reduce violence against sex workers. This is supported by the epidemiological evidence from Vancouver that showed that the introduction of more severe laws against the purchase of sex alongside fewer sanctions for sex workers (modelled on the Swedish Law) did not result in reduced violence from clients32.33
Despite the fact the Swedish Law was motivated by a desire to end the demand for sex work, findings from our qualitative synthesis suggest that these enforcement strategies that seek to reduce the numbers of sex workers34 or clients 31are unlikely to achieve these effects, since the economic needs of sex workers remain unchanged, resulting in sex workers having to work longer hours, accept greater risks, and deprioritise health. There is no reliable evidence from Sweden that the numbers of sex workers have decreased since the law changed in 1999. 22
In New Zealand, following decriminalisation, sex workers reported being better able to refuse clients and insist on condom use, amid improved relationships with police and managers. However, migrants continue to be excluded from this system. Studies in Guatemala, Mexico, Turkey and Nevada, US showed how regulatory models exacerbate disparities within sex worker communities. They enabled access to safer conditions for some, but excluded the majority (including the most marginalised). Under these models non-compliance with regulatory systems including working in tolerance zones, regulator venues and/or mandatory registration at a health care facility and mandatory HIV/STI testing results in criminalisation.
In conclusion, the public health evidence supports decriminalisation, when coupled with inclusive policies to protect the safety and health of sex workers, including the funding and scale-up of specialist and sex-worker-led services that help address the multiple and diverse health and social care needs of people who sell sex.
October 2019
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