Written evidence submitted by Action for Trans Health
1.1 Action for Trans Health is a UK network of trans activists and organisations campaigning for trans healthcare rights. Our network of individual members and affiliate groups makes us the largest UK campaign for trans healthcare.
1.2 Many of our members and service users are sex workers or used to be sex workers. As such, we consider sex work and the health implications around sex work to be a trans health issue. We submitted written evidence to the recent Women and Equalities Select Committee Inquiry into transgender equality which included evidence around sex work[1], which we have expanded in this document.
1.3 This evidence is based on a literature review as well as short interviews with a number of our members who sell sex or have sold sex.
1.4 We would be happy to provide oral evidence to the inquiry in addition to this written evidence.
2 Overview of Trans People and Sex Work
2.1 Trans people are people whose gender identity differs from the gender assigned to them at birth. Various studies place the trans population at around 1% of the population[2][3], although a study from the Netherlands placed the number of trans people at around 3-4%[4]. This means that the possible UK trans population is between 641,000 and 2,564,000.
2.2 Trans issues are in general an under-studied area, and trans sex work is especially so. As such, information on trans sex workers is scarce.
2.3 In a large study of online profiles selling sex in the UK (n=27,408)[5], it was found that 4% identified as trans (of which, 70% identified as women, 27% as men, and 3% as non-binary); and overall 33% of profiles identified as men, and just under 66% of profiles identified as women. As far as we know this is the only study which has attempted to approximate the number of trans sex workers, but this obviously does not include those who operate solely offline.
2.4 In the above study, 96% of trans sex workers advertised to male clients, 60% did so to female clients and 78% to couples. This is compared to 99% of female sex workers advertising to male clients, 52% to female clients, and 63% to couples, and for male sex workers, 29% advertised to male clients, 95% to female clients, and 80% to couples. No data was found on how many sex workers advertise to trans clients specifically.
2.5 The above study agrees with various other studies which challenge the dominant view that sex work is typically something that takes place solely between a female worker and a male client[6]. Clearly, those undertaking sex work are a diverse crowd, as are their clients.
2.6 The data seems to suggest that trans people, and particularly trans women, disproportionately engage in sex work compared to their cisgender peers. This may be due to a combination of discrimination in more conventional forms of employment and high poverty rates within the trans community[7]. Trans people, and particularly trans youth, are also more likely to be homeless or vulnerably housed compared to their cisgender peers[8].
2.7 Lack of access to healthcare has also been highlighted by our members who are sex workers as a significant driver for their choice to sell sex:
“I kept on getting turned down for interviews when they [employers] found out that I was trans. My dysphoria was really bad and the long waiting lists at Gender Identity Clinics[9] made me feel like I was going nowhere. I had to take my trans treatment private. I started selling sex to pay for my treatment, it was the only thing I could do to keep myself alive” – Sophie[10]
2.8 Sex workers are individuals whose reasons for engaging in or choosing to leave sex work are personal, economic and social – as complex as anyone’s reasons for entering into, engaging in or leaving any type of work. Some of our members stressed that whilst their decision to engage in sex work was impacted by lack of employment options, it was their own choice:
“Before doing sex work full time I was working 2 to 3 jobs on crappy contracts. Sex work, whilst not at all perfect, gave me the chance to work flexibly and on mostly my own terms” – Sam
2.9 Sex workers are routinely discriminated against with regard to healthcare, housing, education and job training. Trans people are also routinely discriminated against with regard to healthcare[11], housing, education[12] and job training. This often leads to a “double discrimination” which adds up to more than the sum of its parts.
3 Health impacts of sex work for trans people
3.1 There is no UK specific data on the HIV prevalence rate amongst trans people, never mind trans sex workers. However, we are aware that trans women sex workers worldwide have a HIV prevalence of 27.7%, compared with a global adult population rate of 0.8%[13].
3.2 Global HIV prevalence in trans women, regardless of whether they engage in sex work, is 19.1%, rising to 21.6% in high income countries[14]. (The UK was not included in this particular study sample).
3.3 High rates of HIV within the trans community is thought to be informed by the almost complete lack of trans inclusive safer sex education in schools, and a lack of trans specific safer sex services.
3.4 The above study into online sex worker profiles found that 11% of trans profiles advertised offered unprotected penetrative sex, compared to 6% of female profiles and 11% of male profiles. Although sex workers usually have more sex with a greater variety of people than the general population, typically they are more likely to engage in safer sex. Various studies suggest that between a third and half of the general population often engage in unprotected casual sex[15].
3.5 There is compelling evidence to suggest that sex workers often act as sex educators, teaching their clients about safer sex practices[16]. This is particularly the case when sex workers have access to good pay and conditions:
“I got into sex work casually at first but I made sure I educated myself on safer sex before meeting my first client. I often end up teaching clients about safer sex cause I know it helps keeps them and my community safe” – Sophie
3.6 We note that global decriminalization of sex work has been estimated would cut HIV transmission by one third worldwide[17]. Whilst this is not UK or trans –specific, we encourage more research into the positive health impacts that are associated with the decriminalization of sex work.
3.7 There is little data on other health impacts associated with sex work within the trans community. We would suggest that just as HIV rates are higher, it is likely that the rate of STI transmission in general is higher within the trans community for similar reasons as mentioned in 3.3.
3.8 We understand that whist data is scarce, the prevalence of drug use and harms associated with drug use is higher in the trans community due to various factors, including mental health inequalities, high poverty rates, and an almost complete lack of trans specific drug and alcohol services. Anecdotally, we know that some trans sex workers are expected or encouraged by clients to engage in drug use whilst working, although this is not always the case.
4 Violence against trans sex workers
4.1 Data on violence facing trans sex workers is limited. We do know that in general, trans people, and particularly trans women and transfeminine non-binary people, face much higher levels of violence, harassment and intimidation than their cisgender peers.
4.2 We know that levels of violence and harassment against trans sex workers in particular is higher than those facing male sex workers, and in some situations, (cis) female sex workers too. As you would expect, sex work on the street is more dangerous for trans sex worker than making incalls or outcalls.
4.3 Trans sex workers can be particularly at risk from violence, harassment, intimidation and not being paid. This can be attributed to the “double discrimination” of being a trans person and a sex worker, bringing higher levels of hate crime. This is particularly the case if they are involved in street work.
4.4 Increased levels of violence against trans sex workers can also be due to that fact that most clients are heterosexual young men, who often seek the services of a trans woman sex worker who has a penis. Clients can sometimes react badly afterwards due to their internalized homo / transphobia, and inflict violence upon the sex worker or refuse to pay (which is another form of violence).
4.5 Sometimes, trans sex workers are also at increased risk when their client does not initially realise that the sex worker is trans. The decision for trans sex workers to disclose their trans status is often a fraught one, as disclosure can often bring the violence described in 4.3 and 4.4, but a client discovering a sex worker’s trans status during or after the fact can also bring violence.
4.6 Globally, the Transgender Day of Remembrance memorial list is a partial attempt to collate a list of trans and gender variant people who have been killed due to transphobic violence. The majority of the people on the list are trans women or trans-feminine people of colour, most of whom engage in sex work, most of whom are either from the global south, or the USA. Thankfully the number of trans people killed in the UK is low, although most of these people were migrant sex workers.
4.7 Trans people in general have very low reporting rates for hate crime, often due to violence and harassment happening so often that it is seen as a matter of course. Trans sex workers are particularly unlikely to report a hate crime or any other crime, for fear of their gender or their work being misunderstood, and often because they face high levels of police harassment.
4.8 Many of our members who engaged in sex work said that they fear working alone and that working with others or having friends near helps them feel safer at work. However, many trans sex workers do not feel able to work alongside others for fear of prosecution:
“I would feel a lot safer knowing another trans person was working alongside me when doing incalls. But even having someone around who isn’t working is dangerous as you risk being raided as a brothel. It means that no-one can have my back whilst I’m working” – Sam
5 Services available to trans sex workers
5.1 There is a significant lack of trans-specific sex worker services available. This is unfortunate as trans sex workers often do not feel able to engage with ‘general’ sex worker services due to fear of transphobia, and an acknowledgement that general sex worker services often cannot meet trans sex worker’s specific needs. However, this lack of service provision often puts trans sex workers at greater risk than their cisgender counterparts.
5.2 Where trans inclusive sex work services exist, they are often tacked onto services for male sex workers. However, for many trans sex workers – the majority of whom identify as women – accessing these services necessarily involves misgendering, and so often trans women sex workers avoid these services.
6 Recommendations: moving towards decriminalization
6.1 We believe that it is fundamentally necessary to protect the human rights of trans sex workers, and that to do so it is necessary for policy makers to listen to the voices of trans sex workers alongside those of their cisgender peers when considering policy and practices that impact their lives.
6.2 We believe that the criminalization of sex workers disproportionately impacts the trans community. Trans people face significant discrimination in various arenas of everyday life, particularly in employment, healthcare, and housing. For many trans people, sex work is necessary for survival, and criminalization only harms an already marginalized community.
6.3 We are also concerned about the criminalization of clients. We believe that calls to criminalize clients rests on the unfounded assumption that sex work is exclusively based around predatory male sexual subjects seeking sex with objectified female sex workers. Whilst this can sometimes be the case, this stereotype erases the rich and complex experiences of LGBT sex workers and often leads to a lack of LGBT and trans specific services, putting LGBT and trans sex workers at greater risk.
6.4 We believe that the criminalization of clients will only lead to higher levels of violence against sex workers as they are forced to undertake unsafe practices to ensure that their client base are not arrested whilst they are working. There is a wealth of evidence to support the claim that criminalisation of clients harms sex workers. We believe trans sex workers are particularly vulnerable in this regard.
6.5 We would also note that where policies exist to criminalize clients and not sex workers, in practice sex workers still face higher levels of prosecution than their clients [21]. We are concerned that a move to criminalize clients may result in a de facto policy of criminalising all aspects of sex work. We also note that such a criminalisation does not have the support of public opinion.
6.6 We would also like to note that in Sweden, where the Swedish model of client criminalisation exists, the policy itself has resulted in increased violence towards sex workers and does not enjoy the support of the majority of practitioners
6.7 We recommend the full decriminalisation of sex work. If sex workers and their clients are not forced to live outside the law, there is much better scope for their human rights to be protect, for violence against sex workers to be reduced, and for improvement of public health.
6.8 We recommend the launch of an HIV prevention scheme targeted at trans people, with a specific focus for trans women and those who engage in sex work. We must create opportunities for trans sex workers to protect themselves, their partners and their clients.
6.9 Alongside this, it is essential that more trans inclusive sexual health services are funded. urrently, GUM services are designed to cater to sexually active people who are not trans. Expansion and funding for more services like CliniQ, who understand and meet the health needs of trans people, are essential.
6.10 The end to illegal and inhumane treatment of sex workers by police – we must crack down on police officers who abuse their powers and demand sex, steal sex workers’ money and perpetuate violence towards sex workers.
6.11 A UK wide piece of research into the experiences of trans sex workers within the UK – we cannot hope to fully meet the needs of trans sex workers without a clear picture of what those needs are.
[1] Action for Trans Health (2015) Submission to the Trans Inquiry http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/women-and-equalities-committee/transgender-equality/written/19666.html
[2] Glen, F and Hurrell, K. Technical note: Measuring Gender Identity (2012) www.equalityhumanrights.com/sites/default/files/documents/technical_note_final.pdf
[3] Clark, TC, Lucassen, MFG, Bullen, P, Denny, SJ, Fleming, TM, Robinson, EM, Rossen, FV. (2014) Health and Well-Being of Transgender High School Students: Results From the New Zealand Adolescent Health Survey; http://www.ncbi.nlm.nih.gov/pubmed/24438852
[4] European Union Agency for Fundamental Rights' (FRA) comparative analysis of EU LGBT survey data.2015; http://fra.europa.eu/en/publication/2014/being-trans-eu-comparative-analysis-eu-lgbt-survey-data
[5] http://www.birmingham.ac.uk/Documents/college-social-sciences/government-society/polsis/research/statistics-on-sex-work-in-the-uk.pdf
[6] See Laing, M., Pilcher, K., & Smith, N. (Eds.). (2015). Queer Sex Work. Routledge.
[7] A 2010 Count Me In study found 26% of trans people are unemployed and a further 60% earn less than 10,000 a year
[8] Data on trans homelessness is scarce but the Albert Kennedy Trust recently released a report suggesting that LGBT people make up a quarter of the UKs homeless youth population. Anecdotally, many LGBT homelessness organisations we work with suggest that the number of trans people who are homeless or vulnerably housed is rising. For the Albert Kennedy Trust report: http://www.lgbtyouthnorthwest.org.uk/wp-content/uploads/2016/01/AlbertKennedy_ResearchReport_Youth-Homelessness.pdf
[9] Waiting times for treatment at Gender Identity Clinics are often much longer, and sometimes several times longer, than the NHS 18 week referral to treatment standard.
[10] Names have been changed.
[11] 2012, Trans Mental Health Study
[12] 2014, NUS, Education Beyond the Straight and Narrow
[13] 2014, Poteat et al. HIV risk and preventive interventions in transgender women sex workers in HIV and Sex Workers 6
[14] 2013, Baral et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. The Lancet infectious diseases, 13(3), 214-222.
[15] See footnote 5.
[16] 2006, Sanders ‘Female sex workers as health educators with men who buy sex: utilising narratives of rationalisations.’ Social Science & Medicine, 62, 2434-2444.
[17] 2015, Shannon et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. The Lancet,385(9962), 55-71
[18] https://www.amnesty.org/en/qa-policy-to-protect-the-human-rights-of-sex-workers/
[19] 2014, Poteat et al. HIV risk and preventive interventions in transgender women sex workers in HIV and Sex Workers 6
[20] 2015, Shannon et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. The Lancet,385(9962), 55-71.
[21] Kingston, S. & Thomas, T. 2014. ‘The police, sex work, and section 14 of the
Policing and Crime Act 2009.’ The Howard Journal of Criminal Justice, 53(3),
255-269.