CME Author: Zeena Nackerdien
Study Authors: Lucy Platt, Pippa Grenfell, et al.
Target Audience and Goal Statement:
Gynecologists, infectious disease specialists, public health professionals, and urologists
The goal is to gain more insights into the extent to which sex laws and policing practices affect sex workers’ safety, health, and access to services, and the pathways through which adverse effects occur from these policies.
Most countries in the world do not have a reliable estimate of the number of prostitutes because of laws and stigma attached to sex work. According to a report published in 2012 by Fondation Scelles, there are 40-42 million sex workers worldwide, three-quarters of whom are 13 to 25 years old. Global revenue from the world’s “oldest profession” is estimated at $186 billion per year. Additionally, 20% to 40% of female sex workers (FSWs) began sex work before age 18 in one study. According to the World Health Organization, FSWs are 13.5% more likely to be living with HIV than other women of reproductive age; this proportion is 30% among Asian FSWs.
Whether sex workers are primary drivers for AIDS “hot spots” worldwide continues to be a controversial topic. A 2016 study highlighted the fact that “the sex industry includes a variety of ‘third party actors’, such as receptionists, managers, advertisers, website providers, drivers, housekeepers, and security guards, who are involved in commercial sex transactions in roles other than direct sellers (e.g., sex workers) or buyers (e.g., clients).” Studies have also found that support by sex managers of condom use and sexual health education in sex work venues is a significant predictor of HIV risk reduction.
However, criminalization of sex-for-pay remains the main legislative model across the globe. Overall, five regulatory models are in place, of which three include criminal penalties:
- Full criminalization: Every aspect of buying and selling sex is prohibited
- Partial criminalization: Organization of sex work is prohibited, e.g., running a brothel
- Criminalization of sex purchase: Any aspect of participation in the sex trade as a third party (e.g., pimping), buying sex, and penalties for sex workers working together (under third party laws). Based on the “Nordic model,” this strategy attempts to protect sex workers
- Regulatory models: Sale of sex is legal based on licensed models and/or managed zones and condoms are frequently mandatory, as well as testing for HIV and other sexually transmitted infections (STIs)
- Full decriminalization: Some countries have a policy where adult sex work is decriminalized, but condom use is legally required in certain locations
The criminalization of sex work and sex workers was a topic at a panel discussion at the 2018 International AIDS Conference (IAC) in Amsterdam, with researchers finding that not even “end demand” laws — which criminalize the clients and sex worker advertising, but not sex workers themselves — help with healthcare access.
Authors of the current analysis said there has been no systematic synthesis of qualitative and quantitative studies to examine the consequences of policing sex work. Therefore, the researchers undertook a mixed-methods review comprising meta-analyses and qualitative synthesis to measure the magnitude of associations and related pathways, between criminalization and sex workers’ experience of violence, sexual (including HIV and STIs) and emotional health, and access to health and social care services.
Study Synopsis and Perspective
“They couldn’t have designed a law better to make it less safe, even if they sat for years! It’s like you have to hide out, you can’t talk to a guy, and there’s no discussion about what you’re willing to do and for how much. The negotiation has to take place afterwards, which is always so much scarier. And you’re in a parking lot somewhere with some dude and all of a sudden he decides he doesn’t want to pay that, or pay anything at all and what are you going to do about it? So, yeah, it’s designed to set it up to be dangerous. I don’t think it was the original intention, but that’s what it does.”
— Anonymous female Canadian quoted in a PhD student’s manuscript
In the current paper appearing in PLoS Medicine, Lucy Platt, PhD, of the London School of Hygiene and Tropical Medicine, and colleagues, conducted a systematic review and meta-analysis of the literature on laws regarding sex work and health status of sex workers. They initially identified 9,148 relevant papers in peer-reviewed journals from 1990 to 2018. A total of 134 studies met the researchers’ inclusion criteria, with 40 included in the quantitative synthesis. Of these, 20 were included in the meta-analysis and 20 in a narrative synthesis. For the qualitative evidence synthesis, 94 papers met the inclusion criteria, of which 46 were included in the thematic analysis, three were excluded following quality assessment, and 45 were excluded when “thematic saturation” had been reached.
Platt and colleagues sought studies that included quantitative measurement of associations among the following: criminalization or decriminalization of sex work; repressive policing practices within these contexts; threatened or enacted violence; HIV/STIs; and access to health/social care services. Qualitative studies that examined the perspectives of the sex workers themselves regarding these issues were also included in the current analysis.
Repressive policing practices of sex workers, on average, were linked to an elevated risk of sexual/physical violence from clients or other partners based on a meta-analysis of nine studies and 5,204 participants. Similarly, repressive policing of sex workers was associated with an increased risk for condom-less sex practices (9,447 participants from four studies) and a separate analysis showed an elevated risk for HIV/STI infections (12,506 participants from 11 studies). More precisely, this strategy was associated with an almost twofold higher risk of HIV or STIs (OR 1.87, 95% CI 1.60-2.19), as well as a higher risk of condomless sex (OR 1.42, 95% CI 1.03-1.94). These policies were also linked to an almost threefold increased risk of sexual or physical violence from clients or other parties (OR 2.99, 95% CI 1.96-4.57).
When examining the nine studies that looked at physical or sexual violence against sex workers, the authors found that physical or sexual violence from clients was higher among those who had been exposed to repressive police activity (OR 2.71, 95% CI 1.69-4.36).
A subgroup analysis of the five studies examining condom use found that “odds of condomless sex with clients was higher following police exposure” (OR 1.42, 95% CI 1.03-1.94). The authors also noted that in studies based in Canada, fear of the police and police harassment was linked to avoiding healthcare services among both cis and trans women.
Notably, the U.S. is among one of three countries in the world, along with South Africa and Sri Lanka, with “full criminalization” of sex work examined in the review, meaning all aspects of selling and buying sex or organization of sex work are prohibited, with the exception of a “legalized brothel system” in Nevada.
However, Platt’s group noted that even in Nevada, it is a crime for a sex worker to test positive for HIV and deliberately expose another human to HIV. Workers who test positive can face up to 10 years in prison if “they are found selling sex in a licensed or an unlicensed environment.”
“[Repressive policing] violations [are] inextricably linked to increased unprotected sex, transmission of HIV and STIs, increased violence from all actors, and poorer access to health services,” the authors wrote.
Study limitations included high heterogeneity in the studies examining condom use and violence, and that studies were limited to those written in either English, Russian, or Spanish. They also noted that “there was a lack of comparable quantitative data on outcomes such as access to services, drug-related harms, and emotional ill health, which precluded the use of meta-analysis.”
Source Reference: PLoS Medicine, Dec. 11, 2018; DOI: 10.1371/journal.pmed.1002680
Study Highlights and Explanation of Findings
Quantitative data clearly show a link between repressive policing within frameworks of full or partial sex work criminalization — including the criminalization of clients and the organization of sex work — and adverse health outcomes. Based on the qualitative evidence, “repressive policing of sex workers, their clients, and/or sex work venues deprioritizes sex workers’ safety, health, and rights and hinders access to due process of law,” the researchers wrote.
By showing how several structural and social factors interplay with criminalization of sex work, this systematic review and meta-analysis adds to the body of evidence of how social and structural factors influence sex workers’ safety and vulnerability to HIV. For migrant workers, fear of deportation may further reduce willingness to report violence and exploitation to police. Moral judgment and fear of prosecution may negatively impact sex workers in regions with laws against homosexuality, transgenderism, and drug use. Simply being labeled a sex worker due to arrests may result in offspring being placed in institutional care. Sex workers may also become homeless if evicted due to landlords’ fear of brothel-keeping charges.
Decriminalization of sex work should be a priority, the researchers suggested. How criminalization and decriminalization interact with other structural factors, policies, and realities (e.g., poverty, housing, drugs, and immigration) in different contexts should also be evaluated in future studies to inform appropriate interventions and advocacy alongside legal reform, according to the investigators.
Molly Walker wrote the original story for MedPage Today.