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The Health and Well-being of Sex Workers in Decriminalised Contexts: A Scoping Review

DOI:10.1007/s13178-022-00779-8
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P.G. Macioti at La Trobe University
P.G. Macioti
Jennifer Power
Jennifer Power
Jennifer Power
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Adam Bourne at La Trobe University
Adam Bourne
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IntroductionSex work decriminalisation is widely supported by public health research and sex worker advocates as the best model to protect the health and rights of sex workers. In order to understand the actual implications of sex work decriminalisation on sex workers’ health, this article reviews and summarises existing research from two sites where sex work has been decriminalised for several years: the Australian state of New South Wales and New Zealand.Methods In July 2021, the authors conducted database and directed searches for academic and grey literature reporting on research with diverse sex workers in NSW and New Zealand since, respectively, 1995 and 2003. The searches were updated in July 2022. Fifty-two different papers, including 33 peer-reviewed articles, were identified and reviewed using a scoping methodology.ResultsThe review describes improvements in the health and well-being, as well as in access to and engagement with health services among diverse sex workers in terms of gender, migration history, cultural backgrounds and type of sex work, in the two jurisdictions. These improvements are linked to the development of peer-based outreach and service provision by and to diverse sex workers in both sites. The review also highlights a number of existing regulatory concerns, including the persisting illegalisation of locational aspects of street-based sex work (NSW) and of non-resident, migrant sex work (New Zealand).Conclusions The authors conclude that evidence from the two countries supports full sex work decriminalisation as a necessary first step in order to start addressing health and social inequalities among this highly diverse and stigmatised population.Policy ImplicationsThe evidence reviewed presents overwhelming support for the full decriminalisation of all forms of sex work, including street-based and migrant sex work. Peer-based service provision by and to diverse sex workers should be promoted and funded.
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Vol.:(0123456789)
1 3
Sexuality Research and Social Policy
https://doi.org/10.1007/s13178-022-00779-8
The Health andWell‑being ofSex Workers inDecriminalised Contexts:
AScoping Review
P.G.Macioti1 · JenniferPower1· AdamBourne1
Accepted: 30 November 2022
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2022
Abstract
Introduction Sex work decriminalisation is widely supported by public health research and sex worker advocates as the best
model to protect the health and rights of sex workers. In order to understand the actual implications of sex work decrimi-
nalisation on sex workers’ health, this article reviews and summarises existing research from two sites where sex work has
been decriminalised for several years: the Australian state of New South Wales and New Zealand.
Methods In July 2021, the authors conducted database and directed searches for academic and grey literature reporting on
research with diverse sex workers in NSW and New Zealand since, respectively, 1995 and 2003. The searches were updated
in July 2022. Fifty-two different papers, including 33 peer-reviewed articles, were identified and reviewed using a scoping
methodology.
Results The review describes improvements in the health and well-being, as well asin access to and engagement with health
services among diverse sex workers in terms of gender, migration history, cultural backgrounds and type of sex work, in the
two jurisdictions. These improvements are linked to the development of peer-based outreach and service provision by and to
diverse sex workers in both sites. The review also highlights a number of existing regulatory concerns, including the persisting
illegalisation of locational aspects of street-based sex work (NSW) and of non-resident, migrant sex work (New Zealand).
Conclusions The authors conclude that evidence from the two countries supports full sex work decriminalisation as a neces-
sary first step in order to start addressing health and social inequalities among this highly diverse and stigmatised population.
Policy Implications The evidence reviewed presents overwhelming support for the full decriminalisation of all forms of sex
work, including street-based and migrant sex work. Peer-based service provision by and to diverse sex workers should be
promoted and funded.
Keywords Sex work· Sex work decriminalisation· Sex workers’ health· Service provision to sex workers· Peer to peer
service provision
Introduction
Within public health research, there is growing consen-
sus that full sex work decriminalisation, understood as the
removal of all sex work-related activities from criminal law
and the regulation of sex work as a form of legitimate labour,
is the best available legislative approach to promote harm
reduction and protect the health and well-being of sex work-
ers (Kim, 2015; Platt etal., 2018; Rekart, 2005; The Lancet,
2014; UNAIDS, 2002). Sex work decriminalisation has been
argued by sex worker advocates, international health and
human rights organisations such as the WHO, UNAIDS and
Amnesty International to be a necessary step to improve
sex workers’ health, facilitate their access to health services,
justice, rights and protection and in the long term, help in
reducing stigma and discrimination directed towards them
(Goldenberg etal., 2021).
Outcomes ofCriminalisation andDecriminalisation
In 2014, The Lancet published a global series on HIV and
sex work in which it was established that, among other ben-
efits, sex work decriminalisation would reduce global HIV
infections by 33–46% in the coming 10years (Shannon etal.,
2015). Four years later, a review found that recommendations
* P. G. Macioti
pg.macioti@gmail.com
1 Australian Research Centre inSex, Health andSociety La
Trobe University, Melbourne, Victoria, Australia
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Armstrong, 2017;Deering et al., 2014;Platt et al., 2018;Shannon et al., 2015;Vanwesenbeeck, 2017). The idea that decriminalising sex work can assure safer working conditions and guarantee human rights has also been supported by many agencies, like UNFPA (United Nations Population Fund), UN Women (United Nations Entity for Gender Equality and the Empowerment of Women), UNAIDS (Joint United Nations Programme on HIV/AIDS), and UNDP (United Nations Development Programme); and relevant human rights and anti-trafficking organisations, such as Human Rights Watch, Amnesty International, and La Strada International (Macioti & Geymonat, 2016;Macioti et al., 2022;TAMPEP, 2015). ...
... The country which is a reference when it comes to decriminalising sex work is New Zealand. Although the New Zealand case has more recently come to be defined as "partial decriminalisation" (Macioti et al., 2022): The 2003 Prostitution Reform Act that decriminalised sex work for New Zealand citizens and permanent residents excluded migrants from its protection, and migrants can be deported if found working as sex workers (Bennachie et al., 2021). In Belgium, since 2022, prostitution has been decriminalised, becoming the first country in the EU and Europe to do so. ...
... The evidence makes a strong case for fully decriminalising adult consensual sex work. Decriminalisation has been considered the best model, including for protecting the health and well-being of sex workers (Macioti et al., 2022), enhancing their access to services and justice (Platt et al., 2018), making the industry safer, and improving human rights of sex workers within all sectors of the sex industry (Abel, 2014). Belgium has adopted it recently, becoming the first country in Europe to do so, and all sound evidence in other countries proves significant improvements since decriminalisation (Abel, 2014;Macioti et al., 2022). ...
Understanding the Impact of EU Prostitution Policies on Sex Workers: A Mixed Study Systematic Review
Article
Full-text available
Introduction There is a growing interest in legislation and policies regarding sex work in the European Union and a debate between two opposite perspectives: prostitution is a form of gender violence or a work lacking legal and social recognition. This review aims to develop an integrative synthesis of literature regarding the impact of prostitution policies on sex workers’ health, safety, and living and working conditions across EU member states. Methods A search conducted at the end of 2020 in bibliographic databases for quantitative, qualitative, and mixed methods peer-reviewed research, and grey literature published between 2000 and 2020 resulted in 1195 initial references eligible for inclusion. After applying the selection criteria, 30 records were included in the review. A basic convergent qualitative meta-integration approach to synthesis and integration was used. The systematic review is registered through PROSPERO (CRD42021236624). Results Research shows multiple impacts on the health, safety, and living and working conditions of sex workers across the EU. Conclusions Evidence demonstrates that criminalisation and regulation of any form of sex work had negative consequences on sex workers who live in the EU in terms of healthcare, prevalence and risk of contracting HIV and STIs, stigmatisation and discrimination, physical and sexual victimisation, and marginalisation due to marked social inequalities, for both nationals and migrants from outside the EU. Policy Implications The evidence available makes a strong case for removing any criminal laws and other forms of sanctioning sex workers, clients, and third parties, which are prevalent in the EU, and for decriminalisation. There is a need for structural changes in policing and legislation that focus on labour and legal rights, social and financial inequities, human rights, and stigma and discrimination to protect cis and transgender sex workers and ethnical minorities in greater commitment to reduce sex workers’ social inequalities, exclusion, and lack of institutional support. These measures could also positively impact reducing and monitoring human trafficking and exploitation.
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... While there is a worldwide movement to decriminalize sex work and normalize the activities of both sex workers and their clients to reduce the stigma toward them (Abel, 2014;Macioti et al., 2022), the stigmatic nature of paying for sex is unremitting. As such, paying for sex as part of traveling spurs MWPS to neutralize external moralities of stigma and shame, to resist characterizations of sex work as "dirty work," and their role in it as "dirty customers" -namely, as consumers of dirty work, who are also physically, socially, or morally tainted by their involvement in it (Neal, 2018). ...
... The exception is decriminalization which means removing all punitive measures against buying, selling, and organizing commercial sex and shifting toward integrating sex work into the labor market to reduce harm and stigma among this highly diverse and stigmatized population (Vanwesenbeeck, 2017). While sex work decriminalization is widely supported by public health research and sex worker advocates as the best model to protect the health and rights of sex workers (Macioti et al., 2022), so far, only the Australian state of New South Wales and New Zealand have adopted such policies (Karlsson, 2022). Therefore, the stigmatizing context within which MPWS operate is still dominant worldwide. ...
The Question of Moral Worth in a Controversial Market: Moral Justification Regimes and Boundary Work Among Israeli Men Who Pay for Sex Abroad
Article
Full-text available
This study examined the internal moral debate that takes place among Israeli men who pay for sex (MWPS) while traveling abroad. We explored how they construct their sense of moral worth and present themselves as moral subjects in light of the intensified stigmatization of their actions. Using the theoretical frameworks of pragmatic morality and boundary work, we conceptualize four main moral justification regimes that MWPS use to construct themselves as moral subjects: Cultural normalization; Conditional freedom of choice; The altruistic act of charity; and Unpacking the Stigma Discourse. The findings highlight how these justification regimes are anchored in three intersecting fields-cultural, spatial, and power relations-which produce various matrices of conflict, compromise, or collaboration in different situations. Thus, the flexible switching between various justification regimes reveals how MWPS define themselves and their activities and negotiate various moral dispositions-akin to various cultural logics-in the context of moral taint and stigma.
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Understanding the health and social wellbeing needs of sex workers in Victoria Understanding the health and social wellbeing needs of sex workers in Victoria
Article
Full-text available
  • Apr 2022
This study explores in depth the health needs of diverse sex workers in Victoria by means of qualitative interviews with 31 sex workers and 17 key stakeholders. It looks at sex workers’ experiences in sexual, general and mental health provision and highlights how their health needs can be shaped by the experience of stigma, criminalisation, and a lack of safe, high-quality services. The research was commissioned by the Department of Health Victoria in order to inform service provision and health services for sex workers. It entails detailed evidence in support of sex work decriminalisation as best model to uphold diverse sex workers' health and wellbeing as well as in support of maximising peer-based service provision.
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Sex Work and Mental Health. Access to Mental Health Services for People Who Sell Sex in Germany, Italy, Sweden, and UK
Article
Full-text available
  • Jun 2021
"Sex Work and Mental Health. Access to Mental Health Services for People Who Sell Sex in Germany, Italy, Sweden, and UK" is the final report of a OSF funded participatory research project based at Hydra e.V.. SWMH conducted 118 in depth interviews with sex workers with mental health needs from diverse sex work sectors, of diverse gender, sexuality, residence status and ethnicities in the four countries. The research found that stigma and judgemental attitudes by practitioners were experienced as greatly influencing both sex workers’ mental health and their access to support. Sweden was the site where stigma was most felt as the primary cause of distress and where it bore the highest weight in preventing sex workers from accessing mental health support. Ultimately, SWMH identified stigma as the greatest, most specific barrier for sex workers to enjoy good mental health and access good quality mental health support. SWMH data in Germany, Italy, Sweden and the UK found that, in order to start addressing sex work stigma in society, full sex work decriminalisation is a necessary first step. Whilst criminalisation exacerbates prejudice and stigma against sex workers and defines them according to strict and misleading victimisation categories, decriminalisation sends the clear message that sex work is work. It also acknowledges that sex workers comprise an extremely diverse population with diverse needs including the fundamental right to access unbiased, non-judgemental health support and be free from discrimination on the basis of their work.
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‘I Wouldn’t Call the Cops if I was Being Bashed to Death’: Sex Work, Whore Stigma and the Criminal Legal System
Article
Full-text available
  • Jun 2021
Discourse on sex work is replete with narratives of risk and danger, predominantly focused on violence and disease. However, the risks instigated by police, maintained by the criminal justice system and sanctioned by the state—criminal laws, licensing laws and targeted policing—receive far less attention. This paper responds to this gap in three ways. First, we examine how stigma manifests in sex workers’ experiences of Australian policing, which act to disincentivise sex workers from accessing criminal legal mechanisms. Second, we illustrate how sex workers are denied victim status as they are seen by law as ‘irresponsible citizens’ and blamed for their experiences of crime. Third, we argue that these factors create conditions in which sex workers must constantly assess risks to access safety and legal redress while structural sex work stigma persists unabated. We conclude that ‘whore stigma’ is entrenched in the criminal legal system and requires a systematic response that necessitates but goes beyond the decriminalisation of sex work.
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‘I Can Lead the Life That I Want to Lead’: Social Harm, Human Needs and the Decriminalisation of Sex Work in Aotearoa/New Zealand
Article
Full-text available
Background Sex work is commonly understood to be a risky occupation. Sex work law debates coalesce around the issue of harm, with differing perspectives regarding what constitutes harm, how harm is produced and what needs to change to mitigate it. While sex work is often portrayed as inherently harmful, sex workers and researchers have challenged this assumption, calling attention to the relationship between harm and policies in place. Criminalisation, in its many and varied forms, is thought to exacerbate harms that can occur in sex work, while decriminalisation is understood as creating conditions conducive to minimising harm. However, the decriminalisation of sex work remains rare, and more research which examines how decriminalisation works in relation to harms is critical. This paper uses the concept of social harm to unpack the implications of sex work policies and examine the experiences of sex workers in New Zealand, where sex work is decriminalised.Methods Semi-structured in-depth interviews were conducted with 46 sex workers in New Zealand in 2018 and 2020 across two studies focused on examining experiences and perceptions of stigma and discrimination in this context. The interviews were thematically analysed using NVivo data analysis software.ResultsThe experiences of participants demonstrate how involvement in sex work had improved their lives in multiple ways. Participants described the importance of sex work in improving their quality of life by ensuring that they could better meet their everyday needs, the autonomy this afforded them and how decriminalisation helped to enable this. The validating impact of decriminalisation in acknowledging sex workers as people with rights is also evident in participant’s experiences.Conclusions Social harm is a framework that can help illuminate socio-economic harms which influence pathways into sex work for some people and the compounding harms of criminalising regimes. The benefits of engaging in sex work are often overlooked in policy debates. Although sex work is not easy work, engaging in sex work can have positive impacts on the lives of people who pursue it. Full decriminalisation of sex work is the only responsible option for societies seeking to reduce harm.
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Risk and risk management in sex work post-Prostitution Reform Act: a public health perspective
Chapter
  • May 2010
Introduction In many countries, including New Zealand, harm minimisation has been the predominant philosophy informing public health policy and underpinning the control of HIV/AIDS and other sexually transmitted infections (STIs). Among the sex worker population, the priority has been to reduce disease transmission through advice on safe-sex practices and to help in the implementation of such practices. Such traditional harm minimisation approaches assume that educating sex workers on HIV/AIDS and informing them of their responsibility in preventing transmission would mean that they would then make rational choices to protect themselves and others (Chan and Reidpath, 2003). Yet the assumption that sex workers are vectors of diseases serves to marginalise and blame sex workers without taking into account issues of poverty, gender, public fear and the law (Chan and Reidpath, 2003). Such structural and political issues need to be taken into account and integrated with health education for a more effective health promotion approach to the sex industry (Scambler and Scambler, 1995; Chan and Reidpath, 2003; Frieden et al, 2005). Public health workers have, therefore, been challenged to take a more holistic approach to health promotion for sex workers (Wolffers and van Beelen, 2003). As well as HIV and other STIs, occupational health and safety issues, which include sexual and mental health, physical violence and coercion, are major health and safety concerns for sex workers and thus the protection of sex workers’ human rights needs to also be addressed for successful harm minimisation. This would necessarily require a harm minimisation approach to also take a human rights approach and encompass law reform to create safer working environments (Sanders, 2004a). Some harm reductionists have endeavoured to take a neutral approach (Lenton and Single, 1998), not taking any stance on decriminalisation or legalisation. These practitioners have, however, tended to take a very narrow view of harm minimisation, focusing on the medical means of promoting health and have been less concerned with structural social issues that also contribute to the overall health and well-being of sex workers (Sanders, 2004a). It was with a broad and encompassing view of harm minimisation that decriminalisation of the sex industry was advocated by public health workers in New Zealand.
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Contested Space: Street-based Sex Workers and Community Engagement
Chapter
  • Jul 2020
Street-based sex workers are part of the community in which they work – some live close to where they work and most contribute to the economy of the community through patronage of cafes, service stations and other shops. Yet they are marginalised and stigmatised and are seldom seen as community members by business owners and residents within that community. This chapter draws on interviews with street-based sex workers, residents, Council representatives and outreach workers in two cities in New Zealand. It discusses the spaces within these two cities where street-based sex work is (and is not) accepted by others in the community, as well as how the tensions within these spaces have been addressed. The chapter argues for a community engagement process to relieve community tensions rather than regulatory approaches, which too often have unintended consequences.
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The Impacts of Decriminalisation for Trans Sex Workers
Chapter
  • Jul 2020
Research that focuses specifically on cis-gender sex workers, has demonstrated that the decriminalization of sex work in New Zealand has significantly improved police/sex worker relationships (cf Armstrong 2016). However, there is an absence of research that addresses the safety needs of, and law enforcement responses towards, transgender and non-binary sex workers, who may face additional challenges in terms of work safety and police protection, and who suffer disproportionately from violence and from intolerance in the community (Harcourt et al. 2001). This chapter draws from qualitative research interviews conducted with trans and non-binary sex workers in Wellington, Auckland and Christchurch from 2016 to 2018. Drawing from these interviews, this chapter explores the impacts of decriminalization on worker perceptions of safety, on their work conditions, on their security practices and on their relationships with law enforcement. While emphasizing the benefits of decriminalization, this chapter will also explore the barriers that may continue to exist for some workers in accessing safe working conditions.
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The Disclosure Dilemma: Stigma and Talking About Sex Work in the Decriminalised Context
Chapter
  • Jul 2020
It is widely understood that sex workers are particularly vulnerable to being impacted by stigma, which has serious consequences. Stigma is thought to be exacerbated by the criminalisation of sex work and means that sex workers often live ‘double lives’ in largely keeping their work a secret from those around them to manage risks. However, very little is known about how stigma operates in a decriminalised context and specifically its impacts on the disclosure dilemma that many sex workers manage. This chapter examines this issue, drawing on in-depth interviews with 20 sex workers in New Zealand. Specifically, this chapter explores participants’ experiences of telling friends and family members about their work, the process of deciding who to tell, and the emotional labour of managing responses to these disclosures. Examining these experiences in the context of decriminalisation, this chapter considers the extent to which this context is helping to foster an environment in which it is safer and more comfortable for sex workers to talk about their work with people in their lives.
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‘People Pay Me for Sex’: Contemporary Lived Experiences of Indigenous Australian Sex Workers
Article
  • Nov 2021
The everyday lived experiences of Indigenous Australian sex workers are often made to be invisible. Frequently, they are embedded and left unrecognised within non-Indigenous sex workers’ experiences; alternately, stereotypes about Indigenous sex workers mean their experiences are often overgeneralised and relegated to discussion of exploitation and victimhood. Based on interviews with Indigenous Australians who identify as sex workers, this article examines what sex work means for Indigenous Australians, their views of sex work, and the factors influencing their reasons for engaging in sex work, to bring their experiences to the forefront of contemporary discussions. This research goes beyond the polarised and simplistic arguments which have circulated in sex workers’ research leading to important understandings of the complex and nuanced choices made in relation to work, finances, gender, sexuality and race.
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A survey of condom use among female sex workers in Northern Sydney; declining condom use for fellatio
Article
  • Sep 2021
Condom use among female sex workers (FSWs) is dynamic. We conducted a survey, by anonymous questionnaire, of condom use among FSWs routinely attending our clinical service in Northern Sydney. Logistic regression models determined associations with inconsistent condom use. All 201 women approached completed a questionnaire. Chinese-born women comprised 67% of participants. The median age was 35 years. Clients requesting unprotected fellatio was reported by 95% of participants, and approximately two-thirds felt pressure to have unprotected fellatio and vaginal sex (VSI). Inconsistent condom use at work was reported by 74% for fellatio and by 24% for VSI. The strongest adjusted association with inconsistent condom use for fellatio was monetary inducement by clients (aOR = 40.7, 95% CI 4.87–340, p = 0.001). The only other significant adjusted association was age ≥ 30 years ( p = 0.02). The strongest adjusted association with inconsistent condom use for VSI was also monetary inducement by clients (aOR = 56.1, 95% CI 9.26–340, p < 0.001). Other significant adjusted associations were Chinese-speaking participants ( p = 0.03) and clients requesting unprotected VSI ( p = 0.02). We report high levels of inconsistent condom use. Health promotion should assist FSWs, particularly those of Chinese ethnicity, develop skills in dealing with pressure for unprotected sex, particularly fellatio.
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