Sex Work, Health and Human Rights: Global Inequities, Challenges and Opportunities for Action is based on a powerful combination of sex worker community and academic evidence that highlights the unacceptable health and social inequities that sex workers in all their diversity continue to face across diverse global and policy contexts. This edited collection was guided by a unique community-academic partnership, developed to ensure that sex workers’ voices were amplified in describing challenges, and presenting solutions and ways forward for research, service delivery, and policymaking.
Interdisciplinary author teams of academic researchers, sex workers and sex worker-led organisations collaboratively developed each chapter to synthesise research evidence as well as highlight lessons learned from local-level experiences across different regions. Together, the chapters provide a comprehensive overview of health and human rights inequities faced by sex workers around the world. They articulate structural determinants of sex workers’ health and occupational outcomes and describe evidence-based interventions and “best practices”, including decriminalisation, community empowerment models, and multi-level, integrated interventions.
While the evidence shows an elevated burden of HIV and sexually transmitted infections and drug-related harms, persistent experiences of violence, human rights violations and unmet sexual and reproductive health needs it also demonstrates that sex workers are not passive recipients of such structural inequity and violence. Rather, as the chapters reveal, sex workers actively resist and demonstrate tremendous resilience in the face of these harms, continuing to mobilise to advocate for improved health, safety, and human rights conditions and policy changes.
Part I: Burden of health and human rights inequities faced by sex workers globally
- The epidemiology of HIV among sex workers around the world: Implications for research, programmes and policy
Authors Viswasam, Rivera, Comins, Rao, Lyons and Baral draw on epidemiological studies and the lived experience of sex workers to describe the global HIV burden among sex workers and the factors that influence this. It also describes coverage of and gaps in interventions to reduce HIV-related inequities faced by sex workers over the past decade. This chapter shows that globally, sex workers face a disproportionate burden of HIV, and continue to face unacceptable gaps in access to HIV prevention, treatment, care and support services. It also highlights current gaps in data, including limited research with communities of cis-men and transgender sex workers, as well as the need for further data focused on the harms of criminalisation and intersectional risks. Key recommendations include national action toward decriminalisation of sex work and scale-up of community empowerment, which remain vital alongside and in tandem with emerging biomedical HIV prevention.
- Global burden of violence and other human rights violations against sex workers
Although violence and other human rights violations are recognised as critical public health and human rights violations, global literature on violence against sex workers remains scant. Authors Argento, Win, McBride, and Shannon illustrate this through a global overview of literature on violence and other human rights violations faced by sex workers, complemented by case studies from community partners in the Asia Pacific region. This chapter highlights the need for legislative reforms to decriminalise all aspects of sex work, end impunity for those who commit violence against sex workers, and ensure that sex workers have legally enforceable rights to occupational health and safety protections. The authors indicate the need for political commitment to reduce broader structural inequities, uphold anti-discrimination and other rights-respecting laws, and reduce stigma and exclusion. They also call for increased funding to support scale-up of community-led empowerment approaches and rights-based strategies to mitigate risk of violence, enable safer work environments, and uphold human rights among sex workers globally.
- Sexual and reproductive health and rights inequities among sex workers across the life course
Chapter 4 addresses sex workers’ lack of access to sexual and reproductive health and rights (SRHR). In this chapter, authors Shapiro and Duff draw on academic evidence and community consultations undertaken by NSWP with sex workers across ten countries to examine barriers to achieving SRHR for sex workers. Findings indicate that whereas HIV and STIs have been a primary focus of many sex worker services and interventions, sex workers face a high burden of unmet sexual and reproductive health services across diverse contexts. Multiple factors – including criminalisation of sex work, a lack of sex worker-specific SRHR models, and the stigmatisation of same sex relationships and gender non-conformance – contribute to barriers to achieving SRHR. The authors recommend increasing support for comprehensive SRHR services for sex workers of all genders; ensuring access to safe, legal, affordable, and non-coercive SRHR services, including abortion; integrating SRHR with HIV and STI services as a ‘one-stop-shop’ model; promoting community-led SRH education programming for sex workers and their clients; and prioritizing broader efforts towards full decriminalisation of sex work, community empowerment models of SRH care, and anti-stigma and discrimination efforts.
- Exploring the protective role of sex work social cohesion in contexts of violence and criminalisation: A case study with gender-diverse sex workers in Jamaica
Work by Logie, Wang, Lalor, Levermore, and Williams in Chapter 5 addresses sex workers’ mental health, examining mental health outcomes in relation to social cohesion among sex workers. In collaboration with two sex worker-led organisations in Jamaica, the findings generated from research with 340 women, men, and gender-diverse sex workers found that enhanced social cohesion was linked to reduced depressive symptoms and violence among participants, thus promoting their health and safety. Based on these findings and review of the literature, the authors describe an urgent need for full decriminalisation of sex work and same-gender sexual practices to advance health and human rights, alongside increased screening for mental health and scale-up of access to mental health services for mitigating the effects of structural stigmas.
- Patterns and epidemiology of illicit drug use among sex workers globally: A systematic review
In Chapter 6, Iversen, Long, Lutnick, and Maher evaluate the health needs of sex workers who use drugs, using a systematic review and community case studies from the St. James Infirmary in San Francisco. A systematic review of 86 studies conducted in 46 countries reveals a 35%, pooled prevalence of lifetime illicit drug use among sex workers. The authors note significant gaps existing in the data quality and availability in this review. Key recommendations included an urgent need for future research in partnership with sex workers to improve the quality and quantity of data on illicit drug use among sex workers and guide the creation, implementation, and evaluation of programs and services that meaningfully address the needs of this population.
Part II: Structural determinants of health and human rights inequities in sex work
- Criminalised interactions with law enforcement and impacts on health and safety in the context of different legislative frameworks governing sex work globally
Work by Krüsi, D’Adamo, and Sernick in Chapter 7 illustrates how the criminalisation and policing of sex work shapes sex workers’ health and safety in the context of different legislative frameworks governing sex work around the world. Based on synthesis of research evidence and sex work community case studies from the global North and South, this chapter shows how sex workers’ occupational health, safety, and human rights are violated and undermined under various criminalised models. These models include full criminalisation, as well as ‘end-demand’ models that criminalise clients and third parties but not sex workers directly. This chapter shows how numerous legislative frameworks sanction and perpetuate structural violence and negative health outcomes for sex workers. It concludes with an evidence-based call for the full decriminalisation of sex work, and highlights the need to include sex workers from all segments of the industry, including those who are marginalised due to racialisation, im/migration status and drug use, in evidence-based policy making.
- Stigma, denial of health services and other human rights violations faced by sex workers in Africa: “My eyes were full of tears throughout walking towards the clinic that I was referred to”
In Chapter 8, authors Richter and Buthelezi describe experiences of stigma, denial of care, and other human rights violations faced by sex workers within health service delivery settings in Africa. They powerfully show that sex workers’ negative experiences with health services act as a severe barrier to the right to health and quality health care – by inhibiting effective treatment, prevention and support for HIV and other health-related needs of sex workers, including sexual and reproductive health, preventative care and mental health. In particular, stigmatising and discriminatory treatment by health care workers and non-clinical staff have a far-reaching negative impact on sex workers, undermining their well-being and access to care. In contrast, positive interactions with health care providers and health services empower sex workers, affirm sex worker dignity and agency, and assist in cultivating healthy behaviour and improved health outcomes. The authors conclude with recommendations for comprehensive, rights-affirming health programmes designed in partnership with sex workers, as well as programmes that focus on strategic and practical sex worker needs in the African context; these programmes should include structural interventions to shift away from outdated criminalised legal frameworks and implement violence prevention strategies, psycho-social support services, sex worker empowerment initiatives, and sex worker-led programmes.
- Criminalisation, health and labour rights among im/migrant sex workers globally
Chapter 9 focuses on the health and social needs of women, men, and gender-diverse im/migrant sex workers. Authors McBride and Janushev draw on research evidence and community consultations in Europe to showcase the unique concerns of im/migrant workers in destination settings, based on their intersecting identities as sex workers as well as im/migrants. These concerns include racialised police harassment and surveillance, mandatory health testing, economic marginalisation, discrimination and language barriers. Results of community consultations, primarily among male and gender diverse im/migrant sex workers, illustrate a range of obstacles created by such social and structural exclusion, as well as the resilience of im/migrant workers in their efforts to resist them. Recommendations for policies and programmes include supporting safer indoor sex work environments, removal of punitive sex work, immigration, and public health laws and policies that affect im/migrant sex workers, and supporting non-stigmatising, sex worker-led education, outreach and services.
Part III: Evidence-based services and best practices: Opportunities for action
- Opportunities for action sex worker-led provision of services in New Zealand: Optimising health and safety in a decriminalised context
In Chapter 10, work by Abel and Healy draw on academic research and experiences of the New Zealand Prostitutes Collective to compellingly illustrate how New Zealand’s national decriminalisation of sex work promotes best practices for occupational health, safety, and the broader social inclusion of sex workers. In stark contrast to criminalised settings, where sex workers fear coming forward to report violence due to mistrust of police and fear that they or their workplaces may be prosecuted, this work reports improved access to justice and police responsiveness to violence against sex workers under decriminalisation. Furthermore, this chapter reveals that decriminalisation promotes interagency collaboration to support safer indoor work environments and helps to ensure that new sex workers are well informed about safe and legal sex work practices. Nonetheless, gaps are noted, in particular for migrant workers who are not protected under this law. The authors conclude with recommending full decriminalisation of sex work that is also inclusive of im/migrant workers, so that all sex workers may benefit from improved occupational health, safety, and agency.
- Best practices and challenges to sex worker community empowerment and mobilisation strategies to promote health and human rights
Chapter 11 describes the ways in which community empowerment and mobilisation strategies have, in the last few decades, become critical tools used by sex workers in many settings to confront the health and human rights challenges they face, including HIV, violence, discrimination and labor rights abuses. In this chapter, authors Navarrete Gil, Ramaiah, Mantsios, Barrington and Kerrigan review the literature on community empowerment and mobilisation, highlighting their effectiveness with case studies developed by sex work community organizations APROASE in Mexico and Ashodaya Samithi in India. The authors also identify several evidence gaps, including a lack of systematic community empowerment-based approaches and evaluation of these for male and transgender sex workers. Key recommendations include efforts to take community empowerment efforts to scale and to conduct additional longitudinal evaluation research assessing long-term changes across diverse contexts.
- Reimagining sex work venues: Occupational health, safety and rights in indoor workplaces
Features of sex workers’ occupational environments are known to greatly shape health outcomes. In Chapter 12, authors West, Hilton, Montgomery, and Ebben describe the health and safety challenges, protective factors, and unique considerations and opportunities associated with indoor sex work. A case study from Empower in Thailand, a sex worker-led organisation, outlines the physical and policy components essential to ensuring sex workers’ rights, occupational safety, and health in an indoor workplace. The authors conclude indoor venues pose important potential for establishing and implementing occupational health and safety standards in sex work, and also may provide substantial opportunity for collective organising given the close proximity of people working together. However, any efforts to improve the health and safety of sex workers must explicitly address the structural conditions that lead to power imbalances and which undermine sex worker agency and equality. Key recommendations include promoting occupational health and safety within indoor spaces, prioritising sex worker leadership and inclusion through community mobilisation and engagement efforts, and advocacy and policy reform to remove punitive policies.
- Integrated interventions to address sex workers’ needs and realities: Academic and community insights on incorporating structural, behavioural and biomedical approaches
Finally, in Chapter 13, Schwartz, Viswasam and Abdalla highlight that the intersecting and multi-factorial factors that influence sex workers’ health in most settings are too complex to be addressed with single disease-focused interventions. This chapter synthesises scientific evidence on existing approaches to designing and evaluating multi-level and integrated interventions to improve sex workers’ health, which is complemented by sex work community perspectives from the Kenya Sex Workers Alliance (KESWA). This chapter highlights the necessity for integrated, multi-level public health approaches – including tailored combinations of structural, behavioral and bio-medical interventions – to promote improved health outcomes for sex workers (e.g., HIV, gender-based violence, SRHR). The chapter also discusses challenges and considerations in the development and evaluation of such interventions, including the need for additional support and prioritisation for meaningful sex worker involvement. The chapter concludes with recommendations for further intervention research that incorporates and evaluates structural intervention components, as well as the critical need to support increased opportunities for leadership from the sex worker community in setting and implementing this research agenda.