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      Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies

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          Abstract

          Background

          Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers’ safety, health, and access to services, and the pathways through which these effects occur.

          Methods and findings

          We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96–4.57), HIV/STI (OR 1.87, 95% CI 1.60–2.19), and condomless sex (OR 1.42, 95% CI 1.03–1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

          Conclusions

          Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

          Abstract

          Lucy Platt and colleagues provide qualitative and quantitative evidence demonstrating the extensive harms associated with criminalisation of sex work.

          Author summary

          Why was this study done?
          • To our knowledge there has been no evidence synthesis of qualitative and quantitative literature examining the impacts of criminalisation on sex workers’ safety and health, or the pathways that realise these effects.

          • This evidence is critical to informing evidenced-based policy-making, and timely given the growing interest in models of decriminalisation of sex work or criminalising the purchase of sex (the latter recently introduced in Canada, France, Northern Ireland, Republic of Ireland, and Serbia).

          What did the researchers do and find?
          • We undertook a mixed-methods review comprising meta-analyses and qualitative synthesis to measure the magnitude of associations, and related pathways, between criminalisation and sex workers’ experience of violence, sexual (including HIV and sexually transmitted infections [STIs]) and emotional health, and access to health and social care services.

          • We searched bibliographic databases for qualitative and quantitative research, categorising lawful and unlawful police repression, including criminal and administrative penalties within different legislative models.

          • Meta-analyses suggest that on average repressive policing practices of sex workers were associated with increased risk of sexual/physical violence from clients or other partners across 9 studies and 5,204 participants.

          • Sex workers who had been exposed to repressive policing practices were on average at increased risk of infection with HIV/STI compared to those who had not, across 12,506 participants from 11 studies. Repressive policing of sex workers was associated with increased risk of condomless sex across 9,447 participants from 4 studies.

          • The qualitative synthesis showed that in contexts of any criminalisation, repressive policing of sex workers, their clients, and/or sex work venues disrupted sex workers’ work environments, support networks, safety and risk reduction strategies, and access to health services and justice. It demonstrated how policing within all criminalisation and regulation frameworks exacerbated existing marginalisation, and how sex workers’ relationships with police, access to justice, and negotiating powers with clients have improved in decriminalised contexts.

          What do these findings mean?
          • The quantitative evidence clearly shows the association between repressive policing within frameworks of full or partial sex work criminalisation—including the criminalisation of clients and the organisation of sex work—and adverse health outcomes.

          • Qualitative evidence demonstrates how repressive policing of sex workers, their clients, and/or sex work venues deprioritises sex workers’ safety, health, and rights and hinders access to due process of law. The removal of criminal and administrative sanctions for sex work is needed to improve sex workers’ health and access to services and justice.

          • More research is needed in order to document how criminalisation and decriminalisation interact with other structural factors, policies, and realities (e.g., poverty, housing, drugs, and immigration) in different contexts, to inform appropriate interventions and advocacy alongside legal reform.

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          Most cited references 126

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          The social structural production of HIV risk among injecting drug users.

          There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. Drawing on a review of recently published literature, we seek to describe the social structural production of HIV risk associated with injecting drug use. We adopt an inclusive definition of the HIV 'risk environment' as the space, whether social or physical, in which a variety of factors exogenous to the individual interact to increase vulnerability to HIV. We identify the following factors as critical in the social structural production of HIV risk associated with drug injecting: cross-border trade and transport links; population movement and mixing; urban or neighbourhood deprivation and disadvantage; specific injecting environments (including shooting galleries and prisons); the role of peer groups and social networks; the relevance of 'social capital' at the level of networks, communities and neighbourhoods; the role of macro-social change and political or economic transition; political, social and economic inequities in relation to ethnicity, gender and sexuality; the role of social stigma and discrimination in reproducing inequity and vulnerability; the role of policies, laws and policing; and the role of complex emergencies such as armed conflict and natural disasters. We argue that the HIV risk environment is a product of interplay in which social and structural factors intermingle but where political-economic factors may play a predominant role. We therefore emphasise that much of the most needed 'structural HIV prevention' is unavoidably political in that it calls for community actions and structural changes within a broad framework concerned to alleviate inequity in health, welfare and human rights.
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            Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series

            The GRADE-CERQual (‘Confidence in the Evidence from Reviews of Qualitative research’) approach provides guidance for assessing how much confidence to place in findings from systematic reviews of qualitative research (or qualitative evidence syntheses). The approach has been developed to support the use of findings from qualitative evidence syntheses in decision-making, including guideline development and policy formulation. Confidence in the evidence from qualitative evidence syntheses is an assessment of the extent to which a review finding is a reasonable representation of the phenomenon of interest. CERQual provides a systematic and transparent framework for assessing confidence in individual review findings, based on consideration of four components: (1) methodological limitations, (2) coherence, (3) adequacy of data, and (4) relevance. A fifth component, dissemination (or publication) bias, may also be important and is being explored. As with the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach for effectiveness evidence, CERQual suggests summarising evidence in succinct, transparent, and informative Summary of Qualitative Findings tables. These tables are designed to communicate the review findings and the CERQual assessment of confidence in each finding. This article is the first of a seven-part series providing guidance on how to apply the CERQual approach. In this paper, we describe the rationale and conceptual basis for CERQual, the aims of the approach, how the approach was developed, and its main components. We also outline the purpose and structure of this series and discuss the growing role for qualitative evidence in decision-making. Papers 3, 4, 5, 6, and 7 in this series discuss each CERQual component, including the rationale for including the component in the approach, how the component is conceptualised, and how it should be assessed. Paper 2 discusses how to make an overall assessment of confidence in a review finding and how to create a Summary of Qualitative Findings table. The series is intended primarily for those undertaking qualitative evidence syntheses or using their findings in decision-making processes but is also relevant to guideline development agencies, primary qualitative researchers, and implementation scientists and practitioners. Electronic supplementary material The online version of this article (10.1186/s13012-017-0688-3) contains supplementary material, which is available to authorized users.
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              Matrix product ansatz for Fermi fields in one dimension

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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS Med
                plos
                plosmed
                PLoS Medicine
                Public Library of Science (San Francisco, CA USA )
                1549-1277
                1549-1676
                11 December 2018
                December 2018
                : 15
                : 12
                Affiliations
                [1 ] Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
                [2 ] Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
                [3 ] Department of Criminology, University of Leicester, Leicester, United Kingdom
                [4 ] Bar Hostess Empowerment and Support Programme, Nairobi, Kenya
                [5 ] University of Toronto, Toronto, Ontario, Canada
                Massachusetts General Hospital, UNITED STATES
                Author notes

                The authors have declared that no competing interests exists.

                Article
                PMEDICINE-D-18-00490
                10.1371/journal.pmed.1002680
                6289426
                30532209
                © 2018 Platt et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 4, Tables: 3, Pages: 54
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000919, Open Society Foundations;
                Award ID: OR2015-24978
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100000278, Department for International Development;
                Award ID: http://STRIVE.lshtm.ac.uk/
                Funding for this study was provided by Open Society Foundations (OR2015-24978) and the UK Department for International Development (DFID) as part of STRIVE, a 6-year programme of research and action devoted to tackling the structural drivers of HIV ( http://STRIVE.lshtm.ac.uk/). No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                People and Places
                Population Groupings
                Professions
                Sex Workers
                Social Sciences
                Sociology
                Criminology
                Police
                People and Places
                Population Groupings
                Professions
                Police
                Social Sciences
                Sociology
                Sexual and Gender Issues
                Sex Work
                Social Sciences
                Sociology
                Criminology
                Policing
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
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                Immunodeficiency Viruses
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                Biology and Life Sciences
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                Immunodeficiency Viruses
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                RNA viruses
                Retroviruses
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                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
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                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Pathogens
                Microbial Pathogens
                Viral Pathogens
                Retroviruses
                Lentivirus
                HIV
                Biology and Life Sciences
                Organisms
                Viruses
                Viral Pathogens
                Retroviruses
                Lentivirus
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                Medicine and health sciences
                Public and occupational health
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                Medicine and Health Sciences
                Mental Health and Psychiatry
                Custom metadata
                The data underlying the quantitative synthesis are provided as Supporting Information. The data underlying the qualitative synthesis exist within the underlying publications, which are referenced in the paper.

                Medicine

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