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

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.