Diversity in Healthcare, Psychopathology and Writing and Rhetoric (Due 24 hours)

APA format

1) Minimum 8 pages (No word count per page)- Follow the 3 x 3 rule: minimum of three paragraphs per page

You must strictly comply with the number of paragraphs requested per page

The number of words in each paragraph should be similar

Part 1: minimum 2 pages

Part 2: minimum 2 pages

Part 3: minimum 2 pages

Part 4: minimum 2 pages

Submit 1 document per part

2)¨******APA norms

The number of words in each paragraph should be similar

Must be written in the third person

All paragraphs must be narrative and cited in the text- each paragraph

The writing must be coherent, using connectors or conjunctive to extend, add information, or contrast information.

Bulleted responses are not accepted

Don’t write in the first person

Do not use subtitles or titles

Don’t copy and paste the questions.

Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks)

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references (APA format) per part not older than 5 years (Journals, books) (No websites)

All references must be consistent with the topic-purpose-focus of the parts. Different references are not allowed

5) Identify your answer with the numbers, according to the question. Start your answer on the same line, not the next

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

Q3. Research is…………………………………………………. (a) The relationship between……… (b) EBI has to

6) You must name the files according to the part you are answering:

Example:
Part 1
Part 2

__________________________________________________________________________________

The number of words in each paragraph should be similar

Part 1: Diversity in Healthcare

Case:

Mary and Elmer’s fifth child, Melvin, was born 6 weeks prematurely and is 1-month old. Sarah, age 13, Martin, age 12, and Wayne, age 8, attend the Amish elementary school located 1 mile from their home. Lucille, age 4, is staying with Mary’s sister and her family for a week because baby Melvin has been having respiratory problems, and their physician told the family he will need to be hospitalized if he does not get better within 2 days.

1. Show Mary why medical services (prenatal care) are essential for her and her children (One paragraph)

2. Show Mary why reproductive care (prenatal care) is essential for her and her children (One paragraph)

3. Explain what you know and/or need to learn about Amish values to discuss perinatal care in a culturally congruent way (Two paragraphs)

4. Discuss one consideration per each area, when preparing to do prenatal education classes with Amish patients (Two paragraphs: One paragraph for a and b; one paragraph for c and d)

a Values

b. Beliefs

c. Practices

d. Medical assistance

Part 2: Psychopathology

Case Study: J.T.

Purpose:

Analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.

Scenario:

J.T. is a 20 year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. J.T. has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college.

You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors.

1. According to criteria DSM-5 (ONLY), explain a primary diagnosis for the case (One paragraph)

2. According to criteria DSM-5 (ONLY), explain two primary differential diagnoses for the case (Two paragraphs)

3. Develop a biopsychosocial plan of care for this client. (One paragraph)

4. Compare and contrast fear, worry, anxiety, and panic.(Two paragraphs)

Part 3: Writing and rhetoric

Topic: Deaths caused by school shootings clearly show the need to develop programs to improve students’ mental health.

Audience: Professor

Purpose: Explain what you learned by comparing two very different texts

According to the two articles attached (Check files)

1. Describe one major difference in (One paragraph)

a. Audience

b.Purpose

c. Literature genre

2. Summarize each of your sources (Two paragraphs: One paragraph for article 1; One paragraph for article 2)

3. Discuss how their arguments compare (Two paragraphs)

a. What do they agree on?

b. How did they build on each other?

c. What did you learn from one source that you didn’t learn from the other source?

d. Which do you think was most useful to helping you understand the topic and why?

e. Was that related to the information included, or the way that information was “packaged”?

4. Analyze the rhetorical choices made by each text, paying particular attention to how the sources differ. You’ll want to consider how they are different (in terms of audience, purpose, and genre) including (One paragraph):

a. What stylistic choices they make

b. How their differences shape how these texts can participate in the conversation.

Part 4: Writing and rhetoric

Topic: Recognizing sex work would allow women in this industry to unionize and access benefits that workers in other industries have

Audience: Professor
Purpose: Explain what you learned by comparing two very different texts
According to the two articles attached (Check files)
.
1. Describe one major difference in (One paragraph)
a. Audience
b.Purpose
c. Literature genre
2. Summarize each of your sources (Two paragraphs: One paragraph for article 1; One paragraph for article 2)
3. Discuss how their arguments compare (Two paragraphs)
a. What do they agree on?
b. How did they build on each other?
c. What did you learn from one source that you didn’t learn from the other source?
d. Which do you think was most useful to helping you understand the topic and why?
e. Was that related to the information included, or the way that information was “packaged”?
4. Analyze the rhetorical choices made by each text, paying particular attention to how the sources differ. You’ll want to consider how they are different (in terms of audience, purpose, and genre) including (One paragraph):
a. What stylistic choices they make
b. How their differences shape how these texts can participate in the conversation.

PERSPECTIVES

Mental Illness, Mass Shootings, and the Future of
Psychiatric Research into American Gun Violence

From t
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Jonathan M. Metzl, MD, PhD, Jennifer Piemonte, MS, and Tara McKay, PhD

Abstract: This article outlines a four-part strategy for future research in mental health and complementary disciplines that
will broaden understanding of mass shootings and multi-victim gun homicides. First, researchers must abandon the
starting assumption that acts of mass violence are driven primarily by diagnosable psychopathology in isolated “lone
wolf” individuals. The destructive motivations must be situated, instead, within larger social structures and cultural
scripts. Second, mental health professionals and scholars must carefully scrutinize any apparent correlation of violence
with mental illness for evidence of racial bias in the official systems that define, measure, and record psychiatric diagno-
ses, as well as those that enforce laws and impose criminal justice sanctions. Third, to better understand the role of firearm
access in the occurrence and lethality of mass shootings, research should be guided by an overarching framework that
incorporates social, cultural, legal, and political, but also psychological, aspects of private gun ownership in the
United States. Fourth, effective policies and interventions to reduce the incidence of mass shootings over time—and to
prevent serious acts of violencemore generally—will require an expanded body of well-funded interdisciplinary research
that is informed and implemented through the sustained engagement of researchers with affected communities and other
stakeholders in gun violence prevention. Emerging evidence that the coronavirus pandemic has produced a sharp in-
crease both in civilian gun sales and in the social and psychological determinants of injurious behavior adds special ur-
gency to this agenda.

Keywords: gun violence, mass shootings, mental illness, psychiatric research, racial justice

Indiscriminate shooting rampages in public places accounted
for approximately 0.5%of homicides in the United States in
2019,1,2 yet an estimated 71% of adults experienced fear of

mass shootings as “a significant source of stress in their lives,”
causing 1 out of 3 people to avoid certain public places, accord-
ing to a national survey by the American Psychological Associ-
ation.3,4 In their responses to heightened community concerns
over the threat of mass shootings, numerous public officials in
recent years have pointed to “mental illness” as a simplified ex-
planation for these terrifying acts of violence.5 The “deranged
shooter” narrative resonates with a persistent (if largely false)
belief amongmajorities of adults in the United States: the notion
that people diagnosed with serious psychiatric disorders such as

he Department of Medicine, Health, and Society (Drs. Metzl and
), Vanderbilt University; Joint Program in Psychology and Women’s
nder Studies, University of Michigan (Ms. Piemonte).

l manuscript received 18 February 2020; revised manuscripts re-
25 June and 6 October 2020, accepted for publication subject to revi-
October 2020; revised manuscript received 2 November 2020.

pondence: Jonathan Metzl, MD, PhD, 300 Calhoun Hall, 2301
ilt Place,Nashville, TN37235-1665. Email: jonathan.metzl@vanderbilt.edu

ght © 2021 The Author(s). Published byWolters Kluwer Health, Inc. on
f the President and Fellows of Harvard College. This is an open access
distributed under the terms of the Creative Commons Attribution-Non
ercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissi-
ownload and share the work provided it is properly cited. The work cannot
ged in any way or used commercially without permission from the journal.

0.1097/HRP.0000000000000280

d Review of Psychiatry

schizophrenia are likely or very likely to be violent.6 This con-
struction of the problem relies on an elastic and pejorative
definition ofmental illness and places psychiatrists in an often
unwelcome yet strategic spotlight.7

On the one hand, the public’s a priori definition of mass
shooters as seriously mentally ill invites and reinforces unrealistic
expectations that mental health experts should be able to predict
andprevent acts ofmass violence. It tends to inspire public support
for restrictive policies and interventions targeting psychiatric pa-
tients.6 On the other hand, the “deranged shooter” story can give
mental health professionals a powerful voice and audience—
people look to them for answers and solutions—which trans-
lates into opportunities to reframe the debate over what should
actually be done about mass shootings in the United States.

What can psychiatrists and other mental health clinicians,
researchers, and policy makers do to foster evidence-based solu-
tions topreventmass shootings, and tomitigate thepopulation risk
of firearm injuries in general, without adding to the burden of
stigma and social rejection that people who are recovering from
mental illnesses may feel when others assume they are dangerous?

Existing scientific evidence paints a complex—if incomplete
—picture of the causes of mass shootings and other acts of se-
rious violence. Until recently, a congressional ban on federal
funding for most gun-related research has prevented scientists
and scholars from conducting the full range of interdisciplinary
studies that would provide a better understanding of the prob-
lem and point the way to effective solutions.8

www.harvardreviewofpsychiatry.org 81

mailto:jonathan.metzl@vanderbilt.edu

http://creativecommons.org/licenses/by-nc-nd/4.0/

J. Metzl et al.

In what follows, we outline a four-part strategy for future
research in mental health and complementary disciplines that
will broaden our understanding of these tragic events and
how to effectively prevent them.

First, researchers must abandon the starting assumption
that acts of mass violence are driven primarily by diagnosable
psychopathology in isolated “lone wolf” individuals, and
must rather situate such destructive motivations within larger
social structures and cultural scripts. Second, mental health
professionals and scholars must carefully scrutinize any ap-
parent correlation of violence with mental illness for evidence
of racial bias in the official systems that define, measure, and
record psychiatric diagnoses, as well as those that enforce
laws and impose criminal justice sanctions. Third, to better
understand the role of firearm access in the occurrence and le-
thality of mass shootings, research should be guided by an
overarching framework that incorporates social, cultural, le-
gal, and political, but also psychological, aspects of private
gun ownership in the United States; what is needed is a
sustained inquiry into how these dimensions might shape
the contours of gun violence as a broader public health prob-
lem. Fourth, effective policies and interventions to reduce the
incidence of mass shootings over time—and to prevent seri-
ous acts of violence more generally—will require an ex-
panded body of well-funded interdisciplinary research that
is informed and implemented through the sustained engage-
ment of researchers with affected communities and other
stakeholders in gun violence prevention. Emerging evidence
that the coronavirus pandemic has produced a sharp increase
both in civilian gun sales and in the social and psychological
determinants of injurious behavior—especially inmarginalized
communities—adds special urgency to our agenda.9

Acts of mass murder implicate the psychologies of perpe-
trators. A better understanding of the reasons behind their
behaviors—a kind of “rationality within irrationality”10—re-
mains important to the hope of preventing such crimes in the
future.11 Retrospective analyses suggest that a nontrivial minor-
ity of high-profile mass shooters demonstrated clinical symp-
toms, including paranoia, depression, and delusions, at some
point in their lives.12–14 Still, the assumption thatmass shootings
are driven solely or even primarily by diagnosable psychopa-
thology stretches the limits ofmental health expertise. It also sets
up a false expectation that advancing neuroscience and better
therapies tomanage psychiatric symptomswill provide “the an-
swer” to solving gun violence. There is no existing or forthcom-
ing unified theory of impaired brain functioning or of cognitive,
mood, or behavioral dysregulation that could adequately ex-
plain mass shootings or multiple-victim gun homicides.

Symptoms of mental illness by themselves rarely cause vio-
lent behavior and thus cannot reliably predict it. Certain psychi-
atric symptoms, such as paranoid delusionswith hostile content,
are highly nonspecific risk factors that may increase the relative
probability of violence, especially in the presence of other cata-
lyzing factors such as substance intoxication.15,16 Yet the abso-
lute probability of serious violent acts in psychiatric patients

82 www.harvardreviewofpsychiatry.org

with these “high risk” symptoms remains low. In general, fo-
cusing on individual clinical factors alone leaves too much
unexplained, as it tends to ignore the important social con-
texts surrounding mass shootings and multiple-victim homi-
cides.17 To assume that gun violence is primarily a problem
confined to a perpetrator’s brain may impede inquiry into a
ranges of factors that could be crucial to a full understanding
of mass shootings—factors such as the perpetrator’s sex,
race, socioeconomic status, relationships, attitudes, personal
history, the place where a shooting occurs and the perpetra-
tor’s (dis)connection to it, and the ways in which local gun
cultures and unrestricted access to guns might create the con-
ditions under which these events become more likely.

How canmental health research change the dominant nar-
ratives surrounding mass shootings and multiple-victim ho-
micides, and thus broaden debates about the community
effects of gun violence? Our selective literature review and re-
search agenda present a strategy for moving beyond the
“diagnose-the-mass-shooter” framework to a perspective
that emphasizes the multi-determined nature of gun trauma.
In so doing, we advocate for broadening the scope of concern
and the potential contribution of mental health experts and
researchers to include the larger gun-violence epidemic, rec-
ognizing its structural dimensions as within their purview, es-
pecially at the intersection with social science, public health,
and other complementary disciplines.

AN AGENDA FOR MENTAL HEALTH RESEARCH
INTO MASS SHOOTINGS AND MULTIPLE-VICTIM
GUN HOMICIDES

1. Move Beyond Simplistic Mass Shooter Profiling and
Media-Driven “Diagnose-the-Shooter” Formulations to
Situate Destructive Motivations Within Larger Social
Structures and Cultural Scripts
Politicians and media commentators often quickly label mass
shooters as “mentally ill” without defining the term and before
any valid psychiatric history is known, simply on the basis of
the aberrant nature of the crime itself: “What sane person could
do such a thing?” Media-stylized accounts of the motivation of
mass shooters tend to rely onmisleading stereotypes of the inher-
ent dangerousness of mental illness. When such accounts are
widely adopted as master explanations for shooting rampages,
the easily recognizable features of the narrative can obscure the
role of many other potentially important contributing factors.
These might include the perpetrator’s stressful economic circum-
stances and level of social disadvantage,maladaptive personality
development in response to early-life trauma, the psychological
sequelae of domestic violence exposure, aggrieved resentment
and smoldering anger against individuals or groups perceived
to be hostile and threatening,18 and male gender and aberrant
constructions of masculinity—all enhanced by the disinhibiting
effects of substance intoxication and easy access to a semi-
automatic firearm. These kinds of vectors and background con-
ditions, often interacting with each other in complex ways, can

Volume 29 • Number 1 • January/February 2021

Future Psychiatric Research into American Gun Violence

be far more germane to comprehending a particular act of mass
violence than a diagnosis of acute psychopathololgy.19

Recent studies suggest that approximately 25% of mass
murderers had exhibited a mental illness, but most of them
had not appeared on the radar of either the mental health or
law enforcement systems.13 Similarly, a Federal Bureau of In-
vestigation (FBI) study of 63 active-shooter incidents between
2000 and 2013 found that 25% of shooters were known to
have been diagnosed with a mental illness of some kind, rang-
ing fromminor tomore serious disorders. The study concluded
that “formally diagnosed mental illness is not a very specific
predictor of violence of any type, let alone targeted violence.”12

These relatively weak associations highlight how mental ill-
nesses in themselves rarely cause violent behavior and are not
reliable predictors of multiple-victim gun crimes.16,20

In some sense, each mass shooting incident is unique. Sub-
stance use comorbidity and a range of putative risk factors
ranging from the shooter’s level of economic distress and
housing insecurity to politically extremist attitudes and ideol-
ogy, to social isolation have been cited as stressors in analyses
of mass shootings.21No single variable emerged as a common
feature of mass shooters. Still, the “diagnose-the-shooter”
narrative persists and furthers a number of stigmatizing ste-
reotypes, such as the notion that persons with mental illness
resemble “ticking time bombs.”11,22 Representations of peo-
ple with mental illness as being irrationally and unpredictably
violent can have real adverse consequences, ranging from
community resistance to the placement of housing and treat-
ment facilities for people with mental illness in particular
neighborhoods, to the escalation of tense interactions be-
tween people with mental illness and law enforcement offi-
cers, often resulting in avoidable arrests and incarcerations
and sometimes ending in fatal shootings by the police.23,24

Defining an appropriate role for mental health practi-
tioners in preventing mass shootings is inherently difficult.
While recent studies have found that the majority of mass
shooters did not show signs of acute psychosis or serious
mood disorder, the estimated prevalence of psychiatric disor-
der is still higher among these perpetrators than in the general
adult population. As we have already suggested, there is some
evidence that certain combinations of clinical symptoms and
affect patterns may temporarily increase risk of gun violence.
Researchers have identified delusions, fixation, and perceived
persecution as clinical symptoms that may precede violent be-
havior.16,25 But does this implicate psychopathology in mass
shooting, and therefore call for psychiatric surveillance and
risk assessment to prevent at least some of these events?

Ironically in this context, disorders such as major depres-
sion and schizophrenia are often marked by psychomotor
slowing, negative affect, intellectual disorganization, social
isolation, and other symptom clusters that would seem to ren-
der a person less likely to plan and implement a complex gun
crime.18,26 It is perhaps not surprising, then, that some studies
have found that persons diagnosedwith these mental illnesses
are less likely than non–mentally ill offenders to use firearms

Harvard Review of Psychiatry

in violent crimes.27 Along these lines, Swanson and col-
leagues28 found that adults with serious mental illnesses in
public behavioral health systems in Florida were at least no
more likely than other adults in the general population to be
arrested for a gun-related violent crime.

A study of individuals who were clinically fixated on
harming members of Congress found that having a psychiatric
diagnosis alone was not associated with aggression or actual
violent behavior. More relevant predictors included the indi-
vidual’s motives and means.29,30 The MacArthur Violence
Risk Assessment Study31 identified a group of 100 repeatedly
violent individuals in a sample of 1136 discharged psychiatric
inpatients but found that psychosis immediately preceded only
12%of violent incidents. The researchers concluded that “psy-
chosis sometimes foreshadows violence for a fraction of
high-risk individuals, but violence prevention efforts should
also target factors like anger and social deviance.”32 In addi-
tion, the MacArthur study found that only 2.4% of the study
participants engaged in any act of firearm-involved violence,
defined to include brandishing or threatening someone with a
gun, over the 12-month follow-up period.31

A large U.S. study of schizophrenia patients in the commu-
nity found that 5.4% of participants engaged in at least one
act of injurious violence during an 18-month follow-up pe-
riod, but baseline symptoms of psychosis or depression did
not predict injurious violence. Rather, the significant predic-
tors were severity of illicit drug use (hazard ratio = 2.93), re-
cent violent victimization (hazard ratio = 3.52), childhood
sexual abuse (hazard ratio = 1.85), andmedication nonadher-
ence (hazard ratio = 1.39).33 These findings would suggest
that the large majority of patients with schizophrenia do not
engage in acts of serious violence, and even when they do,
psychiatric symptoms alone do not provide a sufficient expla-
nation for their violent behavior.

Still, “mental health” remains the focus of many existing
regulations as well as proposed policies to prevent gun vio-
lence in the community. Despite evidence that there is no
strong connection between gun crime and mental illness,2 fed-
eral law since 1968 has prohibited firearm purchase or posses-
sion by anyone with a record of involuntary civil commitment
to a psychiatric hospital or other mental health–related adjudi-
cation.34 A few studies have suggested that this restriction pre-
vents some violent crime—and gun crime, in particular—but
its population-level impact is severely limited since very few
patients are involuntarily committed.35,36 The vast majority
of violent gun crimes are perpetrated by people who would
never be committable to a psychiatric hospital, and the im-
portant correlates of violent behavior tend to be the same in
psychiatric and nonpsychiatric populations—for example,
being young, male, or socially disadvantaged, exposure to
trauma in early life, and using drugs and alcohol to excess.
Future research into mass shootings and other acts of serious
violence should move beyond the diagnostic template that
looks for psychopathology to adequately explain the perpe-
trator’s behavior.

www.harvardreviewofpsychiatry.org 83

J. Metzl et al.

2. Scrutinize any Apparent Correlation of Violence with
Mental Illness for Evidence of Racial Bias in the Official
Systems That Define, Measure, and Record Psychiatric
Diagnoses, as Well as Those That Enforce Laws and Impose
Criminal Justice Sanctions
U.S. popular and political discourse frequently applies the
mental illness descriptor to white male shooters, but analysis
of whiteness itself, or discussions of whiteness as a race or eth-
nicity, are usually omitted from published studies about U.S.
mass shootings.37–39 By contrast, race and ethnicity often
play a key role in accounts of mass shootings when the perpe-
trator is not white. For example, after the 2007mass shooting
at Virginia Tech University perpetrated by a college student of
Korean-American heritage, media outlets reported that
Asian-Americans experienced fear of retaliation and felt
forced to issue an apology on behalf of their “group.”40

A content analysis of news documents covering mass
shootings from 2013 to 2015 found that white and Latinx
male perpetratorsweremore likely to have their crimes attrib-
uted to mental illness than were shootings by black men.41

White men were qualitatively described as more sympathetic
characters than black and Latinx men, who were more often
labeled as violent threats to public safety.41 Despite the popu-
lar stereotype of mass shooters being white, statistically just
over half (57%) of the perpetrators of FBI-defined mass
shootings since the early 1980s have been white, and the ma-
jority of victims of mass shootings in recent years have been
nonwhite individuals.42,43 When a mass shooting occurs
and the identified perpetrator is black, content analysis shows
that politicians’ press briefings, media reports, and research
articles rarely mention mental health and illness in descrip-
tions of the perpetrator. Rather, such incidents are more likely
to be described under rubrics such as “gang disputes,” “drive-
by shootings,” or other forms of “urban” violence, often with
little further elaboration on motives or effects.44,45

These white/black dichotomies in the definition of mass
shootings carry implications for resource allocation for study-
ing these incidents and for potentially interrupting their
causal pathways and mitigating their harmful consequences
to individuals and communities. Defining urban violence as
essentially out-of-range for our concern with mass shootings
makes it much more difficult for researchers to discover the
ways in which these shootings, too—as commonplace as they
have become in certain urban neighborhoods—can have pro-
found and lasting psychological and community effects.46

Mass shootings in urban areas have received little attention
from mental health researchers, and the relatively few studies
on this topic mostly amount to superficial, group-based com-
parisons between urban and suburban perpetrators. For exam-
ple, Knoll47 describes aspects of social identity in summarizing
how urban and suburban perpetrators seem to differ, citing an
urban “honor culture” and strong, group-based “social hierar-
chies” as the context for urbanmass violence, in contrast to the
image an isolated loner who commits amass shooting in a sub-
urban public setting.

84 www.harvardreviewofpsychiatry.org

Meanwhile, a large body of research has focused on the
link between violence and mental illness in general, much of
it relying on data from the criminal justice system, forensic fa-
cilities, state psychiatric hospitals, or other publically funded
systems in the community. Due to the historical nexus of ra-
cial discrimination and economic disadvantage—which had
led indirectly to entrenched disparities in arrest and incarcer-
ation as well as to involvement with the public behavioral
health system—individuals who are identified as violent (or
at risk of violence) in official institutional settings tend to be
disproportionately people of color.48–50

These systems curate and disseminate the records of felony
conviction and involuntary civil commitment that are used to
determine that a person is ineligible to possess firearms under
federal or state law. Specifically, official agencies report
gun-disqualifying records to the FBI’s gun-purchase back-
ground check database, with the result that racial disparities
in the reporting institutions’ practices and policies tend to be
reproduced in the implementation of firearm restrictions that
are applied to putatively risky categories of people.51 As one
example, a large study of gun restrictions in a population of
adults with serious mental illnesses in Florida found that
black individuals made up 15% of the surrounding popula-
tion but 21% of the study group in the public behavioral
health system, 31% of those disqualified from guns due to a
mental health adjudication, and 36% of those disqualified
due to a criminal record.28,49

As a result of these entrenched selection effects, much of
what we know regarding the intersection of violence and
mental illness extends only as far as people with mental ill-
nesses who are socially and economically marginalized or
use public services. But this misleading picture is often used
to justify further institutionalization or incarceration that dis-
proportionately affects people of color, producing an insidi-
ous feedback loop between biased data and discriminatory
practice. Studies that are able to account for a range of social
correlates of violence inmultivariablemodels tend to find that
the statistical association between violence and race is much
attenuated, as is the link between violence and mental illness
as defined in the official records of state agencies.31,52

In summary, racial bias can creep into available data and
distort our understanding ofmass shootings and other gun vi-
olence, limiting the scope of what should be a broader and
more productive inquiry into the complex causes and effects
of gun-related injury and death. What, for instance, are the
psychologies that underlie shootings in areas of concentrated
urban poverty, and what particular traumas emerge in their
wake?53,54 What are the traumatizing effects for young peo-
ple who frequently hear gunshots or have seen shootings or
dead bodies?55,56 How can mental health expertise be effec-
tively deployed to address these more quotidian, but no less
problematic, aspects of gun violence in the United States?

Reckoningwith the biases in its own framework can then aid
mental health research to promote anti-racist work57—such as
collaborating with community-based violence interrupters,58

Volume 29 • Number 1 • January/February 2021

Future Psychiatric Research into American Gun Violence

imagining and advocating for structural change, and addressing
how gun victimization in black communities intersects with
other unequal systems, including health care, education, and
community safety.46

3. Promote Awareness of the Social and Political
Determinants of Firearm Violence
To better understand the role of firearm access in the occur-
rence and lethality of mass shootings and other forms of
gun violence, research should be guided by an overarching
framework that incorporates not only social, cultural, and
political, but also psychological, aspects of private gun own-
ership in the United States. Mental health researchers should
play a key role in a sustained collaborative inquiry into how
these dimensions might shape gun violence as a broader pub-
lic health problem. Following the lead set by public health
scholarship, adopting such an approach would enable mental
health researchers to contribute productively to building in-
terdisciplinary evidence for gun laws and policies that are
both effective and equitable, minimizing potentially adverse
collateral consequences for at-risk individuals who are sub-
ject to restrictions.59Mental health professionals and scholars
could have much to offer, for example, in the development of
better guidelines for restoring firearm rights to persons with
gun-disqualifying records in their remote past.60

A study byReeping and colleagues61 found that stateswith
more permissive gun laws and higher rates of gun ownership
also tend to have higher rates of mass shootings. But do these
patterns mean that gun laws are effective, or do they reflect
the intersectionality of other social and economic differences
among states? Research by Steadman,31 Tuason,62 and others
suggests that serious acts of violence attributed to “mental ill-
ness” often are more robustly associated with socioeconomic
factors that may also be indirectly linked to mental illness, in-
cluding unemployment, insecure housing, histories of trauma,
or lack of access to care.63 Perhaps the broader determinants of
population well-being, illness, injury, and death can indepen-
dently affect all of the following: cultural attitudes toward
gun ownership; responses to social conflict; policies and laws
concerning gun access; the motivations of a mass shooter;
and the probability of being able to carry out an act of mass vi-
olence.64 Understanding such potential connections through
interdisciplinary research that includes a trained mental health
lens could help to both reduce gun violence and improve other
dimensions of population well-being over time.

4. Use Community Engagement to Expand the Scope and
Impact of Research to Prevent Mass Shootings and Other
Gun Violence
Effective policies and interventions to reduce the incidence of
mass shootings and other acts of serious violence will require
an expanded body of well-funded interdisciplinary research
that is informed and implemented through the sustained en-
gagement of researchers with affected communities and other
stakeholders. Within the mental health community, persons

Harvard Review of Psychiatry

with lived experience as well as some family members and ad-
vocates have been loath to engage with gun violence preven-
tion efforts in the past, due to the perception that these
efforts play upon the public’s exaggerated fear of people with
mental illnesses and thus exacerbate the stigma and scorn that
mentally ill individuals feel from others.65

In reality, people in the communitywho are recovering from
seriousmental illnesses often havemore to fear fromother peo-
ple. Like other vulnerable populations,54,66,67 persons diag-
nosed with mental illnesses are statistically more likely to be
victims than perpetrators of violent crime.18,68,69 They repre-
sent between 25% and 58% of those shot and killed by police
officers each year,70,71 and there is an apparent interaction be-
tween race andmental illness when citizens are shot by law en-
forcement officers. A recent study found that when police shot
and killed people in the line of duty, their explanatory reports
applied the label of “mental illness” more than twice as often
to white individuals as to black individuals (32% vs. 15%).72

These findings suggest the need for community-engaged
research to explore how perceptions and potential biases sur-
rounding mental illness and firearms intersect with those that
involve race, gender, and class.73 Such research could help to
dismantle the stigmatizing assumption that mental illness
causes violence, clearing the way for larger debates about
community safety and resource allocation. This step could
be important because studies have found that people who as-
sociate mental illness with danger are less likely to support al-
locating funds to community services and programs designed
for individuals with mental illness.74–77

Future research should determine what are the best practices
for engaging communities in gun violence prevention, and should
better promote existing efforts in that regard. For instance, fol-
lowing the Sandy Hook shooting, the Interdisciplinary Group
on Preventing School and Community Violence recommended
developing channels of communication between schools and
surrounding communities.78 Their report highlights “chan-
nels of efficient, user-friendly communication” and empha-
sizes the importance of ongoing dialogue between different
community stakeholders such as students, parents, health
care providers, security and safety officers, and school admin-
istrators.78 Community-engaged mental health researchers
who are focused on broadening the discussion and inquiry into
why mass shootings occur may occupy a strategic position for
informing and fostering such dialogue among stakeholders.

DISCUSSION
It is important to move beyond a preoccupation with deter-
mining the mental health status of mass shooters and, more
generally, with the question whether “the mentally ill” are
prone to gun violence. This preoccupation has served to limit
the important role that mental health expertise could actually
play in addressing broader questions involving the balance
between the perceived benefits of gun ownership and the risk
that guns may pose in the hands of some persons at certain
times—all in the interest of promoting the well-being of

www.harvardreviewofpsychiatry.org 85

J. Metzl et al.

individuals and society. The ability to acquire reliable data on
the causes and consequences of gun violence was seriously ham-
pered by a decades-long federal ban on funding for gun-related
research at the Centers for Disease Control and Prevention.
That ban, which prohibited any studies that could have been
perceived as promoting gun control, had a chilling effect on all
federal research funding aimed at preventing gun violence. But
now that the ban has been at least nominally lifted and some
new federal funds have been appropriated for such research at
the CDC and National Institutes of Health, the time has come
for mental health experts and researchers to join other scholars
in complementary disciplines and seize the opportunity to build
the next generation of research to prevent violence. They
must develop broad conceptual frameworks and creative
methodologies to study gun violence as the persistent and
multifaceted public health crisis that it is, and to insist on a
level of public investment commensurate with the human
and societal cost that gun violence exacts.

The reviewed literature makes clear that a diagnosis of a
mental illness alone is an negligible factor in any effort to ex-
plain, predict, and prevent mass shootings or other acts of se-
rious gun violence. These tragic events have many individual
and social determinants—from trauma history to substance
dependence, from unemployment and insecure housing to
the proliferation of guns in the community—that may inter-
act with each other in complex ways. Public mass shootings
are still rare events when considered at the population level,
notwithstanding a fearful public’s perception of their fre-
quency and salience; these will always be exceedingly difficult
events to study, predict, and prevent. Filling in the gaps in
knowledge about these events requires a better understanding
of the cultures and contexts that surround guns in America, in
addition to a focus on specific shootings. More broadly,
preventing gun-related injuries and deaths is a collective, so-
cial responsibility. Psychiatry stands to be an agent of change
in promoting interventions and solutions for improving the
health of a community, rather than narrowly addressing the
most sensationalized manifestations of gun violence.

This body of research becomes more salient as gun owner-
ship emerges as an important theme in narratives surrounding
America’s responses to the COVID-19 pandemic and the
reckoning with racism in the aftermath of the killing of
George Floyd.79 Unprecedented surges in gun ownership,80

weapons brandished in the lobbies of statehouses,81 and
armed presence at protests and counter-protests across the
country82 have marked the American pandemic moment.
Mental health experts have also warned of a “perfect storm” for
suicide risk that is especially concentrated in COVID-distressed
communities, with a sharp increase in the socioeconomic
and psychological determinants of self-injurious behavior co-
inciding with an influx of guns, the most lethal of suicide
methods. And while these trends may heighten the risk of
gun-related morbidity and mortality linked to mental illness,
they also illuminate gaps, blind spots, and omissions in men-
tal health expertise: we need to know more.

86 www.harvardreviewofpsychiatry.org

Just like mortality rates from the novel coronavirus, social
vulnerabilities and inequities that contribute to gun trauma
have been exposed and exacerbated by the shift in resources
away from communities that were already at risk. Recent
multiple-victim shootings in cities like Baltimore and
Philadelphia were all the more lethal because first responders
and emergency roomswere already deployed to capacity with
COVID-19 treatment instead.83–85

Future research will need to address ways in which U.S.
gun trauma has morphed in relation to the changing struc-
tures surrounding human interactions.86 For instance, the
possibilities that previously public gun violence is shifting
during the pandemic to private spaces or that it involves
new or different victims are developments that heighten the
urgency of recalibrating risk assessment and mounting inter-
ventions that can reach people where they reside.

Again, people who are already within the mental health
system do not represent the highest-risk groups for many
types of gun violence, such as intimate partner shootings
and other stress-induced and alcohol-fueled tragedies that in-
creasingly occur in private residences during the pandemic.87

Calling the police is not always the most realistic or desired
first step in these delicate situations; mental health experts
might, instead, need to develop new networks through part-
nerships with organizations, technology platforms, and ser-
vices that reach individuals in threatening circumstances.
Here, for instance, mental health knowledge tailored to these
situations could be adapted and disseminated by social media
companies, first responders, employment boards, or other de-
livery services.18

By reframing and broadening their approach tomass-casualty
shootings, mental health professionals and researchers could
move mental health expertise to the fore in promoting firearm
safety in schools, workplaces, and public gatherings, and among
and between differing communities in post-pandemic America.88

Moving beyond diagnostic frameworks and the futile quest to
“foresee” mass shootings will allow mental health research to
more fully address how mass shootings and multiple-victim
homicides occur within broader systems and frameworks. Do-
ing so could broaden our understanding of gun violence and
point the way to fair and effective policy solutions that could
savemany lives, while respecting both the rights of gun owners
and the dignity of persons affected by mental illness.89

Declaration of interest: The authors report no conflicts of in-
terest. The authors alone are responsible for the content and
writing of the article.

This article and the research behind it would not have been
possible without the exceptional support of Jeffrey Swanson,
PhD. His enthusiasm and exacting attention to detail have
been an inspiration, and our findings reflect his ongoing en-
couragement, generosity, and breadth of knowledge.

Volume 29 • Number 1 • January/February 2021

Future Psychiatric Research into American Gun Violence

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2020;25 Mar. https://www.psychiatry.org/newsroom/news-
releases/new-poll-covid-19-impacting-mental-well-being-
americans-feeling-anxious-especially-for-loved-ones-older-
adults-are-less-anxious

Harvard Review of Psychiatry

87. Lennard N. Domestic violence is on the rise with coronavirus
lockdown. The responses are missing the point. Intercept 2020;
13 Apr. https://theintercept.com/2020/04/13/coronavirus-
lockdown-domestic-violence

88. Rosenberg J. Trump says Virginia’s democratic governor
“should be under siege.” Mother Jones 2020;17 Apr. https://
www.motherjones.com/coronavirus-updates/2020/04/trump-
says-virginias-democratic-governor-should-be-under-siege/

89. Medical Director Institute. Mass violence in America: causes,
impacts and solutions. 2019. https://ncvc.dspacedirect.org/
handle/20.500.11990/1528

www.harvardreviewofpsychiatry.org 89

https://www.ssrn.com/abstract=3680050

https://www.psychiatry.org/newsroom/news-releases/new-poll-covid-19-impacting-mental-well-being-americans-feeling-anxious-especially-for-loved-ones-older-adults-are-less-anxious

Domestic Violence Is on the Rise With Coronavirus Lockdown. The Responses Are Missing the Point.

Trump Says Virginia’s Democratic Governor “Should Be Under Siege”

https://ncvc.dspacedirect.org/handle/20.500.11990/1528

NEA News

Uvalde School Shooting Underscores Urgent Need
for Mental Health Resources
A panel, including NEA, PTA, and U.S. Senators Chris Murphy and Bill Cassidy, discusses the

need to �x the youth mental health crisis in the wake of shootings and pandemic.

By: Cindy Long, Senior Writer

Published: 05/26/2022

In the last week of Mental Health Awareness Month and a day after the mass shooting at Robb Elementary School in Uvalde,

Texas, Washington Post Live hosted a panel about the need to increase resources for youth mental health. The discussion

featured Sen. Bill Cassidy (R-La.), Sen. Chris Murphy (D-Conn.), Miana Bryant, founder of Mental Elephant, an organization

that raises awareness about youth mental health and give students resources and access to treatment, Anna King, president of

the National Parent Teacher Association (PTA), and Becky Pringle, president of the National Education Association (NEA).

The isolation, lack of social support, racial unrest and the widespread loss of loved ones during the pandemic, particularly in

Black and brown communities, resulted in a major mental health crisis among students.

Now two back-to-back mass shootings, one targeting Black people at a Bu�alo grocery store, the other targeting young school

children, has intensi�ed the sadness and anxiety of students and school communities.

‘WHAT ARE WE DOING?’

In an impassioned speech on the Senate �oor the day of the Uvalde shooting, Murphy asked fellow lawmakers, “What are we

doing? There are more mass shootings than days in the year… Our kids are living in fear…what are we doing?”

KEY TAKEAWAYS

The mass shooting at an elementary school has shattered an entire Texas community and anguish and anxiety is being felt

nationwide.
1

Panelists said we have more funding to tackle the crisis but we must ensure that funding continues for the many students

who need ongoing support.
2

In the wake of the pandemic and the tragic shootings, it is critical that resources for addressing mental health be made

accessible to more families, students and educators.
3

https://www.nea.org/advocating-for-change/new-from-nea?nea_today=1

https://www.washingtonpost.com/washington-post-live/

https://www.washingtonpost.com/washington-post-live/2022/05/25/youth-mental-health/

https://www.thementalelephant.com/

https://www.pta.org/

http://nea.org/

https://www.nea.org/advocating-for-change/new-from-nea/extreme-need-mental-health-professionals

https://www.nytimes.com/live/2022/05/14/nyregion/buffalo-shooting

https://www.nbcnews.com/news/us-news/live-blog/texas-school-shooting-live-updates-biden-calls-action-gun-laws-19-chil-rcna30427

https://www.cnn.com/videos/us/2022/05/24/chris-murphy-texas-elementary-school-shooting-vpx.cnn

https://www.nea.org/advocating-for-change/new-from-nea/we-country-need-do-more-end-these-senseless-shootings-says-nea

Murphy, who represented the Connecticut district that included Sandy Hook Elementary, where 26 children were slaughtered

in a mass shooting a decade ago, said the Sandy Hook community will never be the same. Now, Uvalde will never be the same.

Even in communities many miles away, “there are children going to school who are scared; there are parents sending their

children to school who are scared,” Murphy said.

In the wake of the pandemic and the mass shootings, Senators

Murphy and Cassidy, who are members of the U.S. Senate Health,

Education, Labor, and Pensions Committee, said there is growing

support for their legislation to reauthorize the federal mental health

and substance use disorder programs signed into law in 2016 as part

of their Mental Health Reform Act. It is set to expire in September of

this year.

The new legislation, the Mental Health Reform Reauthorization Act of

2022 (S.4170) addresses COVID-19’s devastating impact on the national

mental health crisis, especially among children, by building upon the

2016 legislation to improve and expand those programs.

“The bill provides resources to increase pipelines for mental health professionals by expanding training for those who might

not traditionally be providers, like pediatricians,” said Cassidy.

He said it also calls for increased resources for school-based clinics to provide counseling and mental health services,

expanding access through increased distribution of telehealth appointments, and that it will build more coordinated care

programs so that students receive what are called “wrap around services” that include home, school, healthcare and

community touchpoints.

NEA MEMBERS ADVOCATE FOR SOLUTIONS

The mental health crisis, NEA president Becky Pringle said, is a complex problem with complex, comprehensive solutions that

must be the shared responsibility of everyone who touches young people’s lives.

“We need more mental health professionals in our schools and to partner with those in our communities who are not only

addressing academic and social and emotional learning, but also working on the housing and food crisis,” she said. “All of this

is impacting our students’ mental health.”

NEA and local a�liates around the country are negotiating contracts that will bene�t student mental health, Pringle said. For

example, in Los Angeles, educators negotiated for smaller class sizes so that students could receive more individual attention

and educators were better able to notice and address mental health struggles. In Minneapolis, educators negotiated for more

counselors and school psychologists to help ease the mental health crisis. Nationally, NEA is working with the Biden

Administration to direct funds to federal mental health programs for students.

NEA also joined the Texas State Teachers Association (TSTA) to “demand that state and federal policymakers take action to

keep �rearms out of the hands of people who shouldn’t have them, whether that requires enacting new laws or better

enforcing our existing laws.”

Murphy, who is on the record for restrictions on assault weapons, said lawmakers must �nd a path forward in the aftermath of

the tragedy.

“We need to show parents we are not ignoring this and we are going to try to bridge our di�erences,” he said.

Cassidy said he applauded Murphy’s passion on the issue, and that “we have to do what is required to keep this from

happening again.”

THE TIME IS NOW

U.S. Senator Chris Murphy speaks on the Senate �oor after the

shooting at Robb Elementary School in Uvalde, Texas.

https://www.murphy.senate.gov/newsroom/press-releases/murphy-cassidy-introduce-legislation-to-reauthorize-and-improve-upon-historic-mental-health-reform-act-before-september-expiration

https://www.nea.org/advocating-for-change/new-from-nea/school-counselors-and-social-workers-struggle-meet-student-needs

https://www.nea.org/advocating-for-change/new-from-nea/when-we-fight-we-win-utla-strike-ends-historic-agreement

https://www.nea.org/advocating-for-change/new-from-nea/fighting-schools-minnesota-students-deserve

https://www.nea.org/advocating-for-change/covid/funding-the-recovery

PTA president Anna King said it is unimaginable what the Uvalde parents went through waiting to hear about their children.

“Do we not value the lives of our children enough to pass legislation to protect them?” she asked. “We are asking for sensible

gun reform… We are asking for Congress to come up with something to help our students be safe.”

Children everywhere are going to be traumatized, she said. Some students might not want to go back to school. Some will be

asking their parents, can that happen to me?

“I understand not knowing what to tell children,” she said. “It is scary and traumatic on every level.”

COMMUNITIES NEED RESOURCES

In Bu�alo and Uvalde, communities need time to grieve, King said, but students, families and educators everywhere need

tools and resources on how to talk to children about being safe at school and to have more information on mental health.

“What hits me is what Becky Pringle said earlier, that this is a complex issue,” she said. “There are so many things our children

are facing right now…We’re trying to focus on legislation and urging our members of congress right now to increase access to

[mental health services]. So many families don’t have insurance — our schools need counselors and social workers, but there

has to be a continuation of funding so these services can continue. We are asking for resources.”

Bryan of the Mental Elephant said that getting resources to families and caregivers is crucial. Another critical element is to

remove the stigma around mental health, and to talk to students about their feelings and signals of mental health problems.

“Sometimes signs show up before kids are 14,” she said. “There are lots of resources out there for youth mental health, and we

need to make them more accessible.”

King added that the issue needs much more than bandaid solutions.

“The pandemic, racial trauma, an increase in violence, and an increase in prices and the inability to get basic needs met has

been painful,” she said. “I’ve noticed changes in student energy levels. There is more pessimism. Some are unable to move

past the trauma dump they see on social media. Over the past few years the mental health conversation and the push for it

has increased, but the actual mental health of our country, especially of our youth, has dropped dramatically.”

All panelists agreed, more must be done, and now is the time to act.

You can �nd resources at nea.org/mentalhealth and at pta/healthyminds

https://www.thementalelephant.com/resources

https://www.nea.org/student-success/great-public-schools/student-educator-mental-health

https://www.pta.org/home/programs/Healthy-Lifestyles/mental-health

UPDATED PRIVACY STATEMENT Our online privacy statement

has changed as of January

17, 2023.

LaLa B Holston-Zannell, Trans Justice Campaign Manager

June 10, 2020

Sex workers aren’t always a part of the conversation about police brutality, but they

should be. Police regularly target, harass, and assault sex workers or people they think

are sex workers, such as trans women of color. The police usually get away with the abuse

because sex workers fear being arrested if they report. If we lived in a world that didn’t

criminalize sex work, sex workers could better protect themselves and seek justice when

they are harmed.

Protecting sex workers from police violence is just one of the reasons we need to

decriminalize sex work. It would also help sex workers access health care, lower the risk

of violence from clients, reduce mass incarceration, and advance equality in the LGBTQ

community, especially for trans women of color, who are often profiled and harassed

whether or not we are actually sex workers. In 2020 the call for decriminalization has

made progress, but there are still widespread misconceptions about sex work and sex

workers that are holding us back. Some even think that decriminalization would harm
sex workers. That isn’t true.

Here are five reasons to decriminalize sex work that would protect sex workers, help hold

police accountable, and ensure equality for all members of society, including those who

choose to make a living based by self-governing their own bodies.

Decriminalization would reduce police

violence against sex workers

Police abuse against sex workers is common, but police rarely face consequences for it.

That’s partly because sex workers fear being arrested if they come forward to report

abuse. Police also take advantage of criminalization by extorting sex workers or coercing

them into sexual acts, threatening arrest if they don’t comply. Criminalizing sex work

only helps police abuse their power, and get away with it.

If sex work were decriminalized, sex workers would no longer fear arrest if they seek

justice, and police would lose their power to use that fear in order to abuse people.

Work is Real Work, and it’s Time to Treat it That Way

Privacy Statement

LaLa B Holston-Zannell

https://www.aclu.org/blog/criminal-law-reform/arrested-walking-while-trans-interview-monica-jones

https://sexworkersproject.org/downloads/RevolvingDoorFS.html

https://action.aclu.org/send-message/pass-equality-act

Home

Decriminalization would make sex workers

less vulnerable to violence from clients

Like the police, sex workers’ clients can also take advantage of a criminalized

environment where sex workers have to risk their own safety to avoid arrest. Clients

know they can rob, assault, or even murder a sex worker — and get away with it —

because the sex worker does not have access to the same protections from the law.

Sex workers became even more vulnerable to abuse from clients after the passage of

SESTA/FOSTA in 2018. The ACLU opposed this law for violating sex workers’ rights and

restricting freedom of speech on the internet. SESTA/FOSTA banned many online

platforms for sex workers, including client screening services like Redbook, which

allowed sex workers to share information about abusive and dangerous customers and

build communities to protect themselves. The law also pushed more sex workers offline

and into the streets, where they have to work in isolated areas to avoid arrest, and deal

with clients without background checks.

Decriminalization would allow sex workers to

protect their own health

Sex workers sometimes go without medical care out of fear of arrest or poor treatment by

medical staff if it comes out that they are a sex worker. And because the law doesn’t treat

sex work like a real job, sex workers do not have access to employer-based health

insurance, which means that many cannot afford care.

Criminal law enforcement of sex work comes with unjust police practices, like the use of

condoms as evidence of intent to do sex work. As a result, some sex workers and people

who are profiled as sex workers may opt not to carry condoms due to the risk of arrest.

This puts them at risk of contracting HIV and other sexually transmitted diseases.

Decriminalization would advance equality

for the LGBTQ community

Sex work criminalization laws impact the whole LGBTQ community because members of

the community — particularly LGBTQ people of color, LGBTQ immigrants, and

transgender people — are more likely to be sex workers. The passage of anti-sex work

laws like SESTA/FOSTA harms the community by dramatically decreasing incomes,

which further marginalizes members of the trans community, people of color, or those

with low incomes to begin with.

Trans women of color feel the impact of criminalization the most, whether or not we are

sex workers. Police profile us and often press prostitution charges based on clothing or

condoms found in a purse. We can’t go about our lives without fear of being targeted by

police.

If sex work is decriminalized, police would have one less tool to harass and marginalize

trans women of color. Sex workers, and especially trans women, would be more able to

govern their own bodies and livelihoods. Decriminalizing sex work would promote the

message that Black trans lives matter.

https://www.aclu.org/blog/criminal-law-reform/congress-proposes-fight-online-trafficking-harming-sex-workers

Reducing HIV Transmission Requires Decriminalizing Sex Work

Sex Work is an LGBTQ Issue

https://www.aclu.org/blog/criminal-law-reform/congress-proposes-fight-online-trafficking-harming-sex-workers

https://www.aclu.org/blog/criminal-law-reform/arrested-walking-while-trans-interview-monica-jones

https://action.aclu.org/send-message/pass-equality-act

Decriminalization would reduce mass

incarceration and racial disparities in the

criminal justice system

The criminalization of sex work feeds the mass incarceration system by putting more

people in jail unnecessarily. Those incarcerated tend to be trans and/or people of color,

two groups that are already disproportionately incarcerated. One in six trans people have

been incarcerated, and one in two trans people of color.

Incarceration is violent and destructive for everyone, and even more so for trans people.

While incarcerated, trans people are often aggressively misgendered, denied health care,

punished for expressing their gender identity, and targeted for sexual violence.

An arrest on charges of sex work can result in life-changing consequences that last long

past the end of a sentence. A criminal record can prevent you from accessing an accurate

ID, jobs, housing, health care, and other services. It can also lead to deportation for

immigrants. Members of the trans community and sex workers already face

discrimination in many of these systems. A criminal record further marginalizes and

stigmatizes being trans or engaging in sex work.

Decriminalizing sex work would be a major step toward decarceration and reducing

racial disparities in the criminal justice system. It would keep sex workers from being

harmed by the collateral consequences of a criminal record. It would help prevent the

marginalization of sex workers and destigmatize sex work.

How to decriminalize sex work

The ACLU has supported decriminalizing sex work since 1973, and it became an official

board policy in 1975. Since then, affiliates across the country have advocated for

decriminalization at the state level by striking down laws restricting sex workers’ rights,

such as condoms-as-evidence laws.

The fight continues in 2020, with active decriminalization bills in several state

legislatures and advocates pushing elected officials like district attorneys to take pledges

to not prosecute sex work. At the federal level, Congress has introduced the SAFE SEX

Workers Study Act, which would study the effects of SESTA/FOSTA. There is a chance

for progress if we educate each other on sex workers’ rights and pressure elected officials

to decriminalize.

Sex workers deserve the same legal protections as any other people. They should be able

to maintain their livelihood without fear of violence or arrest, and with access to health

care to protect themselves. We can bring sex workers out of the dangerous margins and

into the light where people are protected — not targeted — by the law.

https://www.lambdalegal.org/sites/default/files/transgender_booklet_-_incarcerated

https://www.congress.gov/bill/116th-congress/house-bill/5448/text?format=txt

https://action.aclu.org/send-message/pass-equality-act

RESEARCH ARTICLE

Associations between sex work laws and sex

workers’ health: A systematic review and

meta-analysis of quantitative and qualitative

studies

Lucy PlattID
1*, Pippa Grenfell1, Rebecca Meiksin1, Jocelyn Elmes1, Susan G. Sherman2,

Teela Sanders3, Peninah MwangiID
4, Anna-Louise Crago5

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

* lucy.platt@lshtm.ac.uk

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 qualita-

tive and quantitative research involving sex workers of all genders and terms relating to leg-

islation, 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 out-

comes 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 con-

domless 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 extor-

tion, physical and sexual violence, failure to provide access to justice, and forced HIV test-

ing. It showed that in contexts of criminalisation, the threat and enactment of police

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 1 / 54

a1111111111

OPEN ACCESS

Citation: Platt L, Grenfell P, Meiksin R, Elmes J,

Sherman SG, Sanders T, et al. (2018) Associations

between sex work laws and sex workers’ health: A

systematic review and meta-analysis of quantitative

and qualitative studies. PLoS Med 15(12):

e1002680. https://doi.org/10.1371/journal.

pmed.1002680

Academic Editor: Alexander C. Tsai,

Massachusetts General Hospital, UNITED STATES

Received: February 5, 2018

Accepted: September 20, 2018

Published: December 11, 2018

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.

Data Availability Statement: 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.

Funding: 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

http://orcid.org/0000-0002-0943-0045

http://orcid.org/0000-0002-7252-161X

https://doi.org/10.1371/journal.pmed.1002680

http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pmed.1002680&domain=pdf&date_stamp=2018-12-11

https://doi.org/10.1371/journal.pmed.1002680

http://creativecommons.org/licenses/by/4.0/

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 reduc-

tion opportunities. It discouraged sex workers from carrying condoms and exacerbated

existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evi-

dence 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 con-

duct meta-analyses for others, as well as variable sample size and study quality. Few stud-

ies 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 evi-

dence related to emotional health and access to healthcare beyond HIV/STI testing.

Conclusions

Together, the qualitative and quantitative evidence demonstrate the extensive harms asso-

ciated 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.

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 syn-

thesis to measure the magnitude of associations, and related pathways, between crimi-

nalisation 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, categoris-

ing lawful and unlawful police repression, including criminal and administrative penal-

ties within different legislative models.

Health impact of sex work legislation

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 2 / 54

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.

Competing interests: The authors have declared

that no competing interests exists.

Abbreviations: cis, cisgender; OR, odds ratio; STI,

sexually transmitted infection; trans, transgender.

https://doi.org/10.1371/journal.pmed.1002680

http://STRIVE.lshtm.ac.uk/

• 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 criminali-

sation 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 decriminalisa-

tion 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.

Introduction

Sex workers can face multiple interdependent health risks [1,2]. Between 32% and 55% of cis-

gender (cis) women working mostly in street-based sex work report experience of workplace

violence in the past year [3]. Across diverse settings, both cis and transgender (trans) women

and men in sex work are at increased risk of experiencing violence and homicide [4–6], HIV

infection [7–9], chlamydia and gonorrhoea [10,11], and poorer mental health than their non-

sex-working counterparts [12]. Yet there is considerable variation within sex-working popula-

tions [13,14]. The epidemiological context as well as social and structural factors and power

relations reproduce inequalities within sex-working populations [2,3,8,9]. For example, cis

women working in street-based sex work are more vulnerable to all these outcomes than those

working in off-street settings [15,16]. Many vulnerabilities faced by sex workers are multiplica-

tive, closely linked to poverty, substance use, disability, immigration, sexism, racism, transpho-

bia, and homophobia [17].

Health impact of sex work legislation

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 3 / 54

https://doi.org/10.1371/journal.pmed.1002680

Qualitative literature demonstrates how social policies and structural factors shape the

health and welfare of sex workers. The ‘risk environment’ concept, developed to understand

drug-related harms [18] and adapted to HIV and violence experienced by sex workers [19,20],

examines different types (physical, social, economic, and political) and levels of environmental

influence (micro and macro), in line with broader efforts to address structural determinants of

health [21]. This concept has been used to demonstrate how policing, stigma, and inequalities

interplay to shape sex workers’ vulnerability to HIV [22], violence [23], and lack of access to

healthcare [24] and justice [25,26], and the potential for sex-worker-led interventions to chal-

lenge these harms [27]. Epidemiological evidence documents the associations between macro-

structural factors (laws, housing and economic insecurity, migration, education, and stigma)

and work environment and community factors (policing, work setting and conditions, auton-

omy, and access to health and peer-led services) and sex workers’ risk of violence and HIV

transmission [2,3]. Criminalisation and repressive public health approaches to sex work (e.g.,

mandatory registration and HIV/sexually transmitted infection [STI] testing) have been

shown to hinder the prevention of HIV, where the focus of interventions and research has

been directed [28–30]. Conversely, mathematical modelling has estimated that decriminalisa-

tion of sex work could halve the incidence of HIV among sex workers and their clients over a

10-year period [2], and evidence from New Zealand indicates that sex workers in decrimina-

lised settings report improved workplace safety, health and social care access, and emotional

health [31,32].

Broadly, there are 5 legislative models used to manage, control, or regulate sex work

(Table 1) [33]. Full criminalisation prohibits all organisational aspects of sex work and selling

and buying sex. Partial criminalisation is where some aspects of sex work are penalised (e.g.,

soliciting sex in public for sex workers and/or clients, advertising services, collective working,

or involvement of third parties). In 1999, Sweden criminalised the purchase, but not the sale,

of sex, and various other countries have followed [34]. This ‘criminalisation of clients’ model

typically retains laws against ‘brothel-keeping’, which may in practice also target sex workers

working together. Regulatory models make the sale of sex legal in certain settings (e.g., in

licensed brothels or managed zones) or under certain conditions (e.g., mandatory registration

or HIV/STI testing) but illegal in other settings or for individuals who do not meet registration

requirements or eligibility criteria (e.g., migrants, cis men and trans sex workers, or people liv-

ing with HIV) [35]. Full decriminalisation, implemented in New Zealand in 2003, removes

criminal penalties for adult sex work, emphasises enforcing criminal laws prohibiting violence

Table 1. Sex work legislative models.

Legislative model Broad definition Countries operating these policies�

Full criminalisation All aspects of selling and buying sex or organisation of sex work are prohibited. South Africa, Sri Lanka, US$

Partial criminalisation Organisation of sex work is prohibited, including working with others, running a brothel,

involvement of a third party, or soliciting.

Canada (prior to 2014), India, UK (except

Northern Ireland)

Criminalisation of

purchase of sex

Often referred to as the sex-buyer model. Laws penalise sex workers working together

(under third party laws), any aspect of participating in the sex trade as a third party, and

buying sex.

Canada, France, Northern Ireland, Republic of

Ireland, Norway, Serbia, Sweden

Regulatory models Sale of sex is legal in licensed models and/or managed zones and is often accompanied by

mandatory condom use, HIV/STI testing, or registration.

Australia (some states), Germany, Mexico, the

Netherlands, Senegal

Full decriminalisation All aspects of adult sex work are decriminalised, but condom use is legally required in

some locations (i.e., New Zealand).

New Zealand

�This list summarises examples of countries where these models are implemented and represented in the review only, and is not exhaustive.
$There is some heterogeneity in the implementation of models within countries, including the US, where a legalised brothel system is in operation in Nevada.

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and coercion, and regulates the sex industry through occupational health and safety standards

[36]. All models criminalise coerced sex work and the involvement of minors, and almost all

models—including decriminalisation in New Zealand—prohibit migrants without permanent

residency from working legally or in a regulated environment. In practice the implementation

of these models through bylaws and enforcement practices is complex, and varies between and

within countries and even locally within cities [37,38].

The debate around sex work policy and legislation is highly polarised. Some argue that all

sex work is itself gendered violence and should be repressed—a notion that underpins the

criminalisation of sex workers’ clients [39,40]. Others argue that this fails to recognise the

diversity of experience and identity in the sex industry and the possibility that financial reim-

bursement for sex between adults can be consensual [41]. At a time of increasing political

interest in legislative reform [42–45], there is a critical need to bring together this evidence to

inform policies that protect sex workers’ safety, health, well-being, and broader rights. We con-

ducted a systematic review to synthesise evidence of the extent to which sex work laws and

their enforcement affect sex workers’ safety, health and access to services, and the processes

and pathways through which these effects occur, including in interaction with other macro-

structural, community, and work environment factors.

Methods

Data extraction and quality assessment

Following a protocol with pre-specified search terms, we searched MEDLINE, CINAHL, Psy-

chINFO, Web of Science, and Global Health for public health and social science literature on

studies that combined 3 search domains: (1) sex work, AND (2) legislation OR policing, AND

(3) health (physical or emotional, including violence/safety) OR access to services (including

health, risk reduction, and social care/support). The complete search terms and review proto-

col are attached (S1 Text). Meta-analyses were not pre-specified, since they were subject to

identifying sufficiently homogenous studies in relation to outcomes and definition of

criminalisation.

Three authors screened the sources for inclusion, discussing any uncertainties within the

team; a second person re-reviewed relevant sources when necessary. Quantitative data were

extracted and analysed by LP and JE, and qualitative data synthesised by PG and RM. For qual-

itative and quantitative studies, we defined quality-related criteria adapted from the Critical

Appraisal Skills Programme (CASP) [46] that papers had to fulfil in order to qualify for inclu-

sion: methods and ethics processes described, appropriate study population clearly defined,

and conclusions supported by study findings. Quantitative studies were further assessed

according to appropriateness of study design, data collection methods, and analyses, using

assessment approaches adapted from the Newcastle–Ottawa scale and CASP [46,47]. A full

copy of the quality assessment process for the quantitative studies is available (S1 Table). For

qualitative evidence, confidence in review findings was assessed according to CERQual guid-

ance, taking account of methodological limitations, coherence, adequacy of data, and relevance

of included studies (S2 Text) [48]. Methodological limitations were assessed using CASP

guidelines for qualitative evidence.

Definitions

We included studies with sex workers of all genders who currently or have ever exchanged sex-

ual services for money, drugs, or other material goods. We included research on all models of

sex work legislation and used the following definition of the criminalisation of sex work: ‘a

model of intervention in which the criminal law is used to manage, control, repress, prohibit

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or otherwise influence the growth, instance or expression of prostitution’ [33]. We also

included the use of non-criminal penalties to target sex workers, such as fines and displace-

ment orders, including those that do not formally relate to sex work. Within the broad legisla-

tive models (Table 1), sex work legislation and policing was operationalised into 8 different

categories of police exposure: (1) police repression on an environment in which sex work takes

place (workplace raids, zoning restrictions, and displacement from usual working areas), (2)

recent (within last year) arrest or prison, (3) past arrest or prison, (4) confiscation of condoms

or needles or syringes, (5) extortion (giving police information, money, or goods to avoid

arrest), (6) sexual or physical violence from police (negotiated or forced), (7) fear of police

repression, and (8) registration as a sex worker at a municipal health authority. Where clear

from included papers, we recorded data on gender using the terms ‘cis’ and ‘trans’ to refer to

people who do and do not identify themselves with the gender they were assigned at birth,

respectively. Conscious of cultural diversity in gender identities, we use the term ‘transfemi-

nine’ to describe feminine-presenting trans populations that do not necessarily describe them-

selves as female/women [49]. We did not identify any papers that discussed the experiences of

people who identify their gender as trans male/masculine or non-binary.

Inclusion criteria

We included quantitative, qualitative, and mixed-methods studies published in English, Rus-

sian, or Spanish, and included data specific to the experiences of sex workers. We included

papers that measured quantitative associations between criminalisation or decriminalisation

of sex work, or repressive policing practices within these contexts, and the following outcomes:

threatened or enacted violence, STIs, HIV, hepatitis B/C, overdose, stress, anxiety, depression,

risk practices/management (e.g., working with others, reporting violence, condom use, sharing

needles/syringes), and access to health/social care services (HIV/STI/hepatitis prevention, test-

ing, and treatment; contraception; abortion; opioid substitution therapy and other drug/alco-

hol services; mental health and counselling; primary and secondary care; psychosocial support

services; housing; and social security). We also included studies that reported qualitative data

on the relationships between experiences of criminalisation or decriminalisation and policing

and sex workers’ experiences of violence, safety, health, risk management, and/or accessing

health or social care services, from the perspectives of sex workers themselves.

Data synthesis

We synthesised estimates that adjusted for confounders to assess overall risk of experience of

physical or sexual violence, HIV/STI, and condomless sex, stratified by the categories of

repressive police activities described above. Where multiple policing practice exposures were

presented in the same study, we selected independent estimates in an overall pooled estimate

prioritising recent experience of arrest/prison and the most commonly occurring outcomes.

Studies including sex workers of different genders were pooled together. We applied random

effects models using the DerSimonian and Laird method for all analyses, allowing for hetero-

geneity between studies and converting all effect estimates into odds ratios (ORs) [50]. We

examined heterogeneity with the I2 statistic. We conducted sub-group analyses to describe dif-

ferences in experience of violence and condom use by partner type (client versus intimate part-

ner/other) and by type of violence (physical versus sexual or sexual/physical combined). We

conducted sensitivity analyses to look at overall associations between policing and our speci-

fied outcomes, excluding or pooling studies that did not adjust for confounders or reported

only STI outcomes (self-reported and biological) or composite HIV/STI, and altering the pri-

ority choice of police exposure (from recent arrest/prison to other). We conducted a narrative

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synthesis of outcomes that were too heterogeneous to pool, including access to services (both

mandatory and voluntary uptake of services), harms related to drug use, and emotional health.

Studies that measured associations with registration at the municipal health department were

also synthesised separately, since this policy was less comparable with all others that involved

direct police action. All analyses were conducted using the metafor package in R version 3.4.1

and RStudio version 1.0.143 [51].

For qualitative studies, data were synthesised inductively, iteratively, and thematically.

From the body of eligible papers we first focused on the ‘data-rich’ papers that contributed

substantive or moderate data and analyses relevant to our research questions. Among the body

of papers that had a limited focus on the topic, we then purposively sampled studies that

reported on an under-represented population, setting, legislative model, or health issue of

interest in this review [52] until no new themes emerged (thematic saturation). For the data-

rich papers, we reviewed and wrote summaries of the results and discussion sections, induc-

tively and iteratively drawing out author- and reviewer-identified themes and sub-themes. We

then linked sub-themes and themes to 4 core categories, informed by concepts of structural,

symbolic, and everyday violence that argue that mistreatment, stigma, exclusion, and ill health

often result from intersecting inequalities that become institutionalised and normalised

through policies, practices, and social norms [53]. We paid careful attention to the different

levels and forms of environmental influence within risk environments [18]. Finally, we

reviewed the less data-rich papers (relative to our research questions) against these emerging

categories until they required no further refining. We summarise the core categories narra-

tively with illustrative quotes (Box 1), drawing out findings that help to unpack the quantitative

associations and their causal pathways. Within each category, we pay close attention to pat-

terns by legislative model.

Results

From 9,148 papers identified, 134 studies met the inclusion criteria, resulting in 40 papers

included in the quantitative synthesis, of which 20 were included in the meta-analysis and 20

in the narrative synthesis. A total of 94 met the inclusion criteria for the qualitative synthesis,

of which 46 were included in the thematic analysis, 3 were excluded following quality assess-

ment, and 45 were excluded when thematic saturation had been reached (Fig 1).

Quantitative synthesis

Included quantitative studies. We identified 40 studies that measured the association

between an aspect of police repression of sex workers or their clients and our outcomes of

interest. The majority of the studies were cross-sectional (28) or serial cross-sectional (2); there

were 9 prospective cohorts [27,54–61] and baseline data from 1 randomised control trial [62].

Studies were conducted in a variety of countries representing some but not all of the main sex

work legislative models (Table 1). Partial criminalisation was represented in 10 studies in Can-

ada, 6 studies in India, 3 studies in Russian Federation, 2 studies in Argentina, and 1 each in

Côte D’Ivoire, Spain and UK. Full criminalisation was represented in 3 studies in Uganda, 2

studies in China, and 1 each in Iran, Rwanda, and South Korea. Regulation models were repre-

sented by 8 studies in Mexico. No quantitative studies examined the effects of the criminalisa-

tion of sex purchase in isolation, or the effects of decriminalisation. Outcomes reported

included the following: sexual or physical violence (n = 10) [57–59,63–69], HIV and/or STI

prevalence (n = 15) [54,60,63,67,70–78], condom use (n = 5) [71,74,78–82], access to services

(n = 8) [56,61,63,71,80,83–85], aspects of drug use (n = 6) [27,46,62,63,66,86,87], and emo-

tional ill health (n = 3) [55,60,88]. Two studies focused on the association between

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Fig 1. Flow chart of included qualitative and quantitative studies. SWs, sex workers.

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criminalisation and social and criminal justice factors including further extortion by the

police or history of arrest [63], any contact with the criminal justice system, being a migrant,

and unstable housing [60]. The majority of studies focused on cis women, with the exception

of 6 that included trans women (n = 5) and cis men (n = 1) in Canada and Argentina

[27,55,56,60,61,70]. Location of sex work was diverse across street and off-street settings.

All studies reported an association between lawful or unlawful repressive police actions

towards sex workers and outcomes, of which 21 adjusted for confounders. We synthesised 4

studies that reported an effect estimate associated with a mandatory registration separately

[79,81,89,90] but considered lawful and unlawful repressive police activities within the regula-

tory system as part of the pooled analysis [63,72,91]. Three studies presented effect estimates

associated with a policy change, STIs, and rushing negotiation with clients, and were also con-

sidered separately [57,77,92]. Twenty studies reported on outcomes relating to HIV/STI preva-

lence, violence, and condom use, on which our primary meta-analyses are based.

Characteristics of all studies are summarised in Table 2.

HIV and STI outcomes. Meta-analysis of 12 independent multivariable estimates showed

that any type of repressive police practice was associated with twice the odds of HIV/STI

(12,506 participants, OR 1.87, 95% CI 1.60–2.19), with little heterogeneity between studies

(I2 = 0.0%, 95% CI 0.0%–0.0%, p = 0.99). Sub-group analysis suggested that people who had

their needles/syringes or condoms confiscated had higher odds of HIV/STIs than those who

did not (2,924 participants, OR 2.44, 95% CI 1.76–3.37, I2 = 0.0%, 95% CI 0.0%–0.0%, p =
0.99). Sex workers who had experienced sexual or physical violence from police had higher

odds of HIV/STI compared to those who had not (1,827 participants, OR 2.27 95% CI 1.67–

3.08, I2 = 0.0%, 95% CI 0.0%–98.6%, p = 0.79) (Fig 2).

The overall effect estimate of repressive policing actions on HIV/STI outcomes was main-

tained across sensitivity analyses including those focusing on unadjusted estimates (OR 1.85,

95% CI 1.49–2.30, I2 = 14.0%, 95% CI 0.0%–81.1%, p = 0.32) (S1 Fig), those focusing on HIV

outcomes only (OR 1.88, 95% CI 1.54–2.28, I2 = 0.0%, 95% CI 0.0%–0.0%, p = 0.98), and those

excluding self-reported STI symptoms (OR 1.91, 95% CI 1.58–2.31, I2 = 0.0%, 95% CI 0.0%–

0.0%, p = 0.99) (S4 Fig).

Violence. We pooled data from 9 studies that measured the association between repres-

sive policing activities and experience of physical or sexual violence against sex workers by a

range of perpetrators, including clients, intimate (sex) partners, and police. Random effects

meta-analysis of 9 independent multivariable estimates showed that, overall, repressive polic-

ing was associated with substantially higher odds of any kind of violence (5,204 participants,

OR 2.99, 95% CI 1.96–4.57), but with high heterogeneity (I2 = 83.1%, 95% CI 65.3%–96.0%, p
< 0.001). Sub-group analysis suggested that those who had their needles/syringes or condoms confiscated had higher odds of violence than those who did not (1,696 participants, OR 4.67, 95% CI 1.32–16.54, I2 = 93.9%, 95% CI 76.2%–99.8%, p< 0.01) (Fig 3). This overall association between police repression and violence increased slightly, but was still associated with substantially higher odds of violence, when all unadjusted estimates were pooled from 6 studies (OR 3.15, 95% CI 1.99–4.99, I2 = 78.7%, 95% CI 52.5%–97.4%, p< 0.001) (S2 Fig). Odds of experiencing physical or sexual violence by other people (defined as anyone other than paying clients, including the police) was higher for those who had experienced any type of repressive police activity compared to those who had not (OR 3.72, 95% CI 1.74–7.95, I2 = 84.1%, 95% CI 53.5%–99.0%, p< 0.001). Similarly, physical or sexual violence from clients was higher among those who had been exposed to repressive police activity compared to those who had not (OR 2.71, 95% CI 1.69–4.36, I2 = 80.4%, 95% CI 45.5%–96.3%, p< 0.001) (S4 Fig). Condom use. Five studies measured the association between repressive policing activities and condom use with both paying and non-paying partners. Meta-analysis of 4 independent Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 9 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. Summary of quantitative study characteristics and associations between lawful and unlawful police repression and sex workers’ experience of violence, con- dom use and HIV/STI outcomes, access to services, emotional health, and drug and alcohol use. First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate Partial criminalisation (organisation of sex work and soliciting) Beattie, 2015 [71] (H) India Cross- sectional (serial), n = 5,792 Cis women (home, brothels) Recent arrest (last year) 4.0 Chlamydia 2.4 (1.3–4.6) 1.8 (0.9–3.5) Gonorrhoea 4.5 (1.8–11.1) 2.7 (1.0–7.6) HIV 2.3 (1.5–3.5) 1.9 (1.2–3.1) Reactive syphilis 3.1 (1.9–5.1) 2.6 (1.5–4.1) No condom with last client for anal sex 0.5 (0.2–1.1) 0.8 (0.3–2.1) No condom with last regular partner 1.2 (0.8–1.7) 1.0 (0.6, 1.7) No condom with last sex client 0.7 (0.4–1.1) 0.6 (0.3–1.0) STI clinic in past 6 months 1.5 (0.9–2.5) 1.7 (1.0–3.0) Ever been to an non- governmental organisation meeting 0.9 (0.6–1.4) 1.2 (0.8–1.9) Member of a female sex worker collective 1.3 (0.9–2.0) 1.5 (0.9–2.2) Ever seen a peer educator 1.6 (0.6–4.4) 2.4 (0.8–7.1) Ever been to a drop-in centre 1.7 (1.1–2.7) 1.5 (0.9–2.4) Ever had an HIV test 0.9 (0.5–1.5) 1.2 (0.7–2.0) Deering, 2013 [64] (H) India Cross sectional, n = 1,219 Cis women (street, home, brothels, dabhas [roadside cafes]) Recent arrest (last year) 5.7 Experienced physical or sexual violence by a client (1 year) 1.8 (1.0–3.3) Erausquin, 2015 [74] (H) India Cross sectional (serial), n = 1,680 Cis women (home, highways, rural) Confiscation of condoms (6 months) 7.6 STI symptoms� 2.4 (1.6–3.6) 7.6 Money for sex without condom (6 months) 3.8 (2.6–5.6) 7.6 Inconsistent condom use with clients (7 days) 1.7 (1.2–2.5) Extortion (gave gifts to police to avoid trouble in last 6 months) 14.8 STI symptoms� 2.4 (1.8–3.2) 14.8 Money for sex without condom (6 months) 2.5 (1.8–3.5) 14.8 Inconsistent condom use with clients (7 days) 1.6 (1.2–2.1) Police repression on sex work environment (raid in last 6 months) 36.1 STI symptoms� 2.2 (1.8–2.8) 36.1 Money for sex without condom (6 months) 1.6 (1.2–2.1) (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 10 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. (Continued) First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate 36.1 Inconsistent condom use with clients (7 days) 1.1 (0.9–1.4) Recent arrest (6 months) 14.5 STI symptoms� 1.7 (1.3–2.3) 14.5 Money for sex without condom (6 months) 1.5 (1.1–2.1) Recent arrest or prison 14.5 Inconsistent condom use with clients (7 days) 1.2 (0.9–1.6) Sexual or physical violence (had sex with police to avoid trouble) 11.1 STI symptoms� 2.2 (1.6–3.1) Money for sex without condom (6 months) 2.0 (1.4–2.9) Inconsistent condom use with clients (7 days) 1.2 (0.8–1.6) Erausquin, 2011 [65] (H) India Cross- sectional, n = 835 Confiscation of condoms (6 months) 7.4 Sexual or physical violence from clients 5.6 (3.2–9.8) Extortion (gave gifts to police to avoid trouble in last 6 months) 12.0 Sexual or physical violence from clients 3.2 (2.0–5.0) Police repression on sex work environment (raid in last 6 months) 26.8 Sexual or physical violence from clients 4.6 (3.2–6.8) Recent arrest (6 months) 12.0 Sexual or physical violence from clients 7.1 (4.4–11.4) Sexual or physical violence (had sex with police to avoid trouble) 10.9 Sexual or physical violence from clients 3.1 (1.9–4.9) Patel, 2015 [88] (H) India Cross sectional, n = 1,986 Cis women (street, home, brothel) Ever experienced arrest/ prison N/A Emotional ill health (depression defined through PHQ-2 scale) 1.6 (1.1–2.4) Punyam, 2012 [84] (H) India Cross sectional, n = 1,986 Cis women (street, home) Ever experienced arrest/ prison 14.9 Emotional ill health (depression defined through PHQ-2 scale) 1.1 (0.8–1.4) Physical violence from police (police informed a friend/relative about sex work arrest) 44.6 Emotional ill health (depression defined through PHQ-2 scale) 1.8 (0.9–3.7) Pando, 2013 [78] (H) Argentina Cross sectional, n = 1,255 Cis women (street, private off street) Ever experienced arrest/ prison because of sex work 45.4 HIV 4.4 (1.6–12.0) 1.8 (1.1–3.0) Treponema pallidum 2.1 (1.6–2.8) 1.5 (1.2–1.7) Irregular (not always) use of condoms with client 1.9 (1.3–2.7) 1.1 (0.9–1.4) Irregular (not always) use of condoms with partner 1.3 (0.9–2.0) 1.0 (0.8–1.3) Avila, 2017 [70] (M) Argentina Cross- sectional, n = 273 Trans women Ever experienced arrest 67.9 HIV 1.42 (0.82–2.47) NS Treponema pallidum 2.4 (1.39–4.17) NS (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 11 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. (Continued) First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate Platt, 2011 [67] (H) UK Cross sectional, n = 268 Cis women (massage saunas, flat, independent) Ever experienced arrest/ prison 20.2 STI/HIV$ 1.3 (0.5–3.5) 2.0 (0.6–7.2) Physical violence& from clients (12 months) 2.0 (1.1–3.9) 2.6 (1.1–5.7) Estebanez, 1998 [75] (H) Spain Cross sectional, n = 2,914 Cis women (street, highway, bar, hotel/pension) Ever experienced prison 15.9 HIV 1.1 (0.3–4.2) Cross- sectional, n = 261 Cis women who inject drugs Ever experienced prison 8.4 HIV 1.7 (0.9–3.5) Argento, 2015 [27] (H) Canada Prospective cohort, n = 692 Cis and trans women (street, bars, brothels) Sexual or physical violence (harassment with and without arrest) N/A Use of non-prescription opioids (6 months) 2.4 (1.9–3.0) 1.8 (1.4–2.3) Shannon, 2008 [85] (M) Canada Cross sectional, n = 198 Cis women (street) Police repression on sex work environment (avoidance of healthcare access or harm reduction services due to violence [recent] and policing [presence and harassment]) Availability of health services and syringe availability 6.5 (4.0–10.6) Shannon, 2009 [59] (H) Canada Prospective cohort, n = 205 Cis women Police repression on sex work environment (moved working areas) 44.4 Being pressured by a client into unprotected vaginal or anal intercourse (6 month) 3.3 (1.4–7.6) 3.1 (1.4–7.4) Police repression on sex work environment (zoning restriction due to solicitation or drug charges) 8.8 Being pressured by a client into unprotected vaginal or anal intercourse (6 month) 3.4 (1.3–9.2) 3.4 (1.2–5.0) Shannon, 2009 [58] (H) Canada Prospective cohort, n = 237 Cis women (street) Confiscation of drug use paraphernalia (without arrest) Clients perpetrated sexual or physical violence 1.3 (0.9–2.2) N/A Forced to have sex (penetrative) against your will by someone�� (6 month) 1.2 (0.3–2.0) N/A N/A Physically abused by someone�� (6 month) 2.0 (1.2–3.1) 1.5 (1.0–2.4) Police repression on sex work environment (moved away from main streets) Sexual or physical violence from client 2.2 (1.4–3.4) 2.1 (1.3–3.6) Forced to have sex (penetrative) against your will by someone�� (6 month) 1.4 (0.9–2.3) N/A N/A Physically abused by someone�� (6 month) 1.8 (0.9–3.0) N/A Sexual or physical violence (assault) Sexual or physical violence from client 4.2 (2.3–7.4) 3.4 (2.0–6.0) (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 12 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. (Continued) First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate Forced to have sex (penetrative) against your will by someone�� (6 months) 3.1 (1.6–6.0) 2.6 (1.3–5.2) N/A Physically abused by someone�� (6 months) 2.6 (0.9–3.8) 2.2 (0.8–3.6) Socias, 2015 [60] (H) Canada Prospective cohort, n = 720 Cis and trans women (street, massage brothel) Recent prison (6 months)¥ 41.9 HCV infected 1.6 (1.1–2.2) 11.3 HIV infected 1.3 (0.8–2.0) Injection drug use 2.1 (1.5–2.8) Heavy drinking (� 4 drinks per day) 2.4 (1.5–3.8) 2.0 (1.2–3.0) Not born in Canada 11.1 (4.9–25.3) 3.3 (1.3–8.5) Unstable housing 5.6 (3.4–9.1) 4.3 (2.2–8.6) Goldenberg, 2017 [56] (H) Canada Prospective cohort, n = 66 Cis and trans women Density of displacement due to policing, within 250 m of residence ART interruptions (�2 consecutive days where no ART was dispensed at each semi-annual visit) 1.02 (1.01–1.04) 1.0 (1.0–1.0) Density of police harassment ART interruptions (�2 consecutive days where no ART was dispensed at each semi-annual visit) 1.01 (1.00–1.02) N/A Density of ‘red zone’/ legal restrictions on work areas (within a 250-m buffer of one’s residential location) ART interruptions (�2 consecutive days where no ART was dispensed at each semi-annual visit) 1.34 (1.02–1.75) 1.30 (0.97–1.76) Density of combined spatial criminalisation measures ART interruptions (�2 consecutive days where no ART was dispensed at each semi-annual visit) 1.0 (1.0–1.0) 1.0 (1.0–1.0) Landsberg, 2017 [92] (M) Canada Prospective cohort (3 combined), n = 259 Cis women Enforcement guideline that sought to prioritise the safety of and prevent violence towards sex workers, but continue to arrest clients and third parties Rushed client negotiation due to police presence (last 6 months) measured after introduction of policy compared to before (after 2013 versus before) 1.71 (1.08–2.72) 1.73 (1.03–2.90) n = 100 Men 0.81 (0.27–2.43) NS Duff, 2017 [55] (H) Canada Prospective cohort, n = 545 Cis and trans women Police presence reported to affect where sex workers worked 31.0 Work stress, including job control, psychological demands, work social support, physical demands 0.42 (0.30–0.53) 0.26 (0.14–0.38) Sou, 2017 [61] (H) Canada Prospective cohort, n = 742 Cis and trans women (street, sauna, brothel) Police harassment including arrest (6 months) 39.4 Unmet health need� 1.48 (1.13–1.94) 1.57 (1.15–2.13) Prangnell, 2018 [57] (M) Canada Prospective cohort (3 combined), n = 259 Cis women who inject drugs (street, sauna, brothel) Enforcement guideline that sought to prioritise the safety of and prevent violence towards sex workers, but continue to arrest clients and third parties Physical, sexual violence (6 months) 1.72 (0.78–3.80) 1.09 (0.59–2.04) (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 13 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. (Continued) First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate Stopped, searched, or arrested (last 6 months) 24.3 Physical, sexual violence (6 months) 3.24 (1.78–5.88) 2.42 (1.33–4.40) Wirtz, 2015 [87] (H) Russia Cross sectional, n = 754 Cis women (street, hotel, sauna, station) Police extortion— money, sex, or information 28.4 Injecting drug use (in last 6 months) 3.0 (1.5–5.9) Police extortion— money 22.8 Injecting drug use (in last 6 months) 2.2 (1.1–4.7) Police extortion—sex 5.0 Injecting drug use (in last 6 months) 3.2 (1.2–8.7) Police extortion— information 3.5 Injecting drug use (in last 6 months) 3.0 (0.7–12.8) Odinokova, 2014 [66] (M) Russia Cross sectional, n = 896 Cis women (street, hotel) Sexual or physical violence (sexual coercion in context of police contact in the last 12 months) 38.2 Rape during sex work (ever) 2.1 (1.5–3.0) Decker, 2012 [73] (M) Russia Cross sectional, n = 147 Cis women (street, hotel, saunas, agency, salons) Sexual or physical violence—subotnik# (3 months) 36.6 Any STI^/HIV N/A 2.5 (1.2–5.4) Lyons, 2017 [68] (M) Côte D’Ivoire Cross- sectional, n = 466 Cis women Ever experienced arrest 26.4 Ever experienced physical violence\ 2.96 (1.89–4.63) 2.79 (1.77–4.41) Ever experienced arrest 3.0 Ever experienced physical violence\ 2.23 (0.69–7.21) N/A Ever been harassed or irritated by police because of sex work 31.2 Ever experienced physical violence\ 3.17 (2.07–4.81) 2.86 (1.85–4.41) Ever felt like the police refused protection because of sex work 24.1 Ever experienced physical violence\ 3.03 (1.90–4.83) 2.75 (1.71–4.44) Ever experienced arrest 26.4 Ever experienced sexual violence \ 2.62 (1.72–4.01) 2.60 (1.65–4.90) Ever experienced arrest 3.0 Ever experienced sexual violence\ 3.44 (1.06–11.13) 4.51 (1.23–16.46) Ever been harassed or irritated by police because of sex work 31.2 Ever experienced sexual violence \ 1.80 (1.86–4.19) 2.53 (1.68–3.90) Ever felt like the police refused protection because of sex work 24.1 Ever experienced sexual violence\ 3.14 (2.01–4.89) 2.98 (1.86–4.80) Full criminalisation (selling and buying sex illegal) Qiao, 2014 [80] (H) China Cross sectional, n = 794 Cis women (street, salon, hotels) Ever experienced arrest/ prison 5.7 Inconsistent condom use with clients (1 month) 0.8 (0.4–1.5) N/A Fear of police repression 39.9 Inconsistent condom use with clients (1 month) 1.9 (1.4–2.6) 1.6 (1.0–2.4) Ever experienced arrest/ prison 5.7 HIV testing (1 year) 3.7 (1.8–7.6) 2.7 (1.2–6.2) Fear of police repression 39.9 HIV testing (1 year) 0.8 (0.5–0.9) 0. 8 (0.5–1.1) Ever experienced arrest/ prison 5.7 HIV prevention service^^ 5.6 (1.7–18.4) 4.6 (0.9–23.3) (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 14 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. (Continued) First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate Fear of police repression 39.9 HIV prevention service ^^ 0.6 (0.4–0.8) 0.4 (0.2–0.7) Zhang, 2013 [82] (H) China Cross sectional, n = 720 Cis women (street, brothels, massage parlours) Ever experienced arrest Unprotected sex in the last sex act N/A 2.5 (1.4–4.6) Jung, 2017 [77] (M) South Korea Cross- sectional (serial), n = 2,009 Women (brothels) Sex Trafficking Act introduced in 2005 that criminalised buying and selling sex and closed down brothels Treponema pallidum (comparing 2008 [before policy came into effect] with 2014) 0.29 (0.16–0.52) Gonorrhoea (comparing 2008 [before policy came into effect] with 2014) 0.22 (0.66–0.723) Shokoohi, 2018 [86] (M) Iran Cross- sectional, n = 1,295 Cis women (street, home) Recent experience of prison (12 months) 7.5 Use of crystal methamphetamine (1 month) 2.51 (1.44–4.37) 0.86 (0.47–1.58) Braunstein, 2012 [54] (M) Rwanda Cross sectional, n = 192 Cis women Ever experienced prison 47.0 HIV prevalence N/A 1.8 (1.3–2.6) Rwanda Prospective cohort, n = 397 Ever experienced prison 38.0 HIV seroconversion N/A 1.4 (0.5–3.8) Erickson, 2015 [83] (H) Uganda Cross sectional, n = 400 Cis women Fear of police exposure leading to rushed negotiations with clients 37.3 Dual contraceptive use 0.6 (0.4–0.9) 0.6 (0.4–1.0) Goldenberg, 2016 [76] (H) Uganda Cross- sectional, n = 400 Cis women (bars, clubs, public places, highway) Ever experienced prison 26.5 HIV 1.67 (1.06–2.64) 1.93 (1.17–3.20) Rushed client negotiation because of police presence (6 months) 37.3 HIV 0.99 (0.64–1.52) N/A Muldoon, 2017 [69] (H) Uganda Cross- sectional, n = 400 Cis women (bars, clubs, public places, highway) Rushed client negotiation because of police presence (6 months) 37.3 Sexual or physical violence from clients (last 6 months) 2.28 (1.51–3.46) 1.61 (1.03–2.52) Regulation through registration in certain zones but public soliciting illegal Pitpitan, 2016 [62] (H) Mexico RCT, n = 300 Cis women who inject drugs (street, bar) Confiscation of needle/ syringe 30 Injected with used needle/ syringe −0.51 (SE 0.25) Strathdee, 2011 [91] (H) Mexico Cross- sectional within RCT, n = 620 Cis women who inject drugs (street, bars, massage parlour) Confiscation of syringes instead of arrest 29.0 HIV infection 2.4 (1.2–4.8) 2.4 (1.2–6.5) Extortion (bribes instead of arrest) 63.0 HIV infection 1.6 (0.7–3.5) Beletsky, 2013 [63] (H) Mexico Cross sectional, n = 624 Cis women who inject drugs (street) Confiscation of syringes in last 6 months 48.0 Any STI (gonorrhoea, chlamydia 1.4 (1.0–1.9) HIV infection 2.4 (1.1–5.1) 2.5 (1.1–5.8) Syphilis (based on titre � 1:8) 1.5 (1.1–2.2) (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 15 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 2. (Continued) First author, year [reference] (quality appraisal) Country Study design and sample size Population (setting) Police exposure (time frame) Percent Outcome (time frame) Unadjusted effect estimate Adjusted effect estimate Police requested sexual favours (6 months) 5.9 (4.0–8.6) Sexually abused by police (6 months) 11.7 (6.3–22.0) 12.8 (6.6–24.2) Ever had an HIV test 1.5 (1.1–2.1) Normally injected in public places 1.7 (1.3–2.4) 1.6 (1.1–2.4) Often/always injected with a client around in the last 6 months 0.7 (0.5–1.0) 0.6 (0.4–0.9) Groin injecting 1.9 (1.3–3.0) 1.8 (1.1–2.9) Police officer requested money (6 months) 18.6 (11.8–29.3) Police officer forcibly took money (6 months) 11.8 (8.1–17.3) Emotional ill health+ 1.6 (1.1–2.1) Extortion (bribes instead of arrest) 63.0 HIV prevalence 1.6 (0.7–3.5) Chen, 2012 [72] (H) Mexico Cross sectional, n = 200 Cis women (street, bar venues, truck routes) Ever experienced arrest 28.6 STI symptoms 2.5 (1.1–5.3) 2.3 (1.0–5.0) Recent arrest (last year) 16.5 STI symptoms 2.2 (0.9–5.4) Gaines, 2013 [79] (H) Mexico Cross sectional, n = 181 Cis women (bar) Registration at the Municipal Health Department 52.0 Free condoms available at venue 2.3 (0.8–6.5) 2.4 (0.9–6.1) In a bad financial situation 0.6 (0.3–1.1) 0.7 (0.3–1.6) Non-injection use of methamphetamines in the past month 0.2 (0.1–0.5) 0.3 (0.1–0.6) Ever tested for HIV 6.1 (2.6–14.2) 5.4 (2.3–12.5) Injected cocaine in the past month 0.1 (0.01–1.2) 0.1 (0.01–0.9) Rusch, 2010 [89] (H) Mexico Cross- sectional, n = 331 Cis women (bar) Registration at the Municipal Health Department 44.7 Working in a venue with high HIV/STI (syphilis) prevalence 0.4 (0.2–0.8) 0.5 (0.2–1.0) Sirotin, 2010 [81] (M) Mexico Cross sectional, n = 187 Cis women (street, bar) Registration at the Municipal Health Department 44.7 Any STI (syphilis, gonorrhoea, chlamydia, HIV) 0.4 (0.3–0.6) NS Gonorrhoea 0.3 (0.1–0.7) NS Chlamydia 0.8 (0.5–1.3) NS Any positive syphilis titre > 1:1

0.3 (0.2–0.5) NS

HIV positive 0.4 (0.2–1.0) NS

Unprotected vaginal sex

with clients in the past

month (median

percentage)

0.6 (0.3–1.1) NS

Ever been tested for HIV/

AIDS

4.8 (2.9–7.8) 4.2 (2.3–7.5)

(Continued)

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multivariable estimates (9,447 participants) suggested that on average these practices were

associated with increased odds of not using a condom (OR 1.42, 95% CI 1.03–1.94), with mod-

erate heterogeneity across the studies (I2 = 63.34%, 95% CI 0.0%–98.2%, p = 0.04) (Fig 4).

The overall association between repressive policing activities and condom use increased

when pooling unadjusted estimates from 2 studies (OR 1.76, 95% CI 1.30–2.38, I2 = 0.0%, 95%

CI 0.0%–0.98%, p = 0.46) (S3 Fig). Sub-group analysis suggested that the odds of condomless

sex with clients was higher following policing exposure (OR 1.42, 95% CI 1.03–1.94, I2 =

63.3%, 95% CI 0.0%–98.2%, p = 0.04) or when additional money was offered (OR 1.54, 95% CI

1.10–2.15, I2 = 66.7%, 0.0%–97.8%, p = 0.03). There was no difference in the odds of condom-

less sex with non-paying partners after police exposure (OR 1.0, 95% CI 0.80–1.24, I2 = 0.0%,

95% CI 0.0%–17.7, p = 0.97) (S4 Fig).

Access to services and mandatory testing. Five studies looked at the association between

repressive policing activities and access to health and social care services. One study in India

found that arrest in the last year was associated with increased odds of attendance at an STI

Table 2. (Continued)

First author,

year

[reference]

(quality

appraisal)

Country Study design

and sample

size

Population

(setting)

Police exposure

(time frame)

Percent Outcome (time frame) Unadjusted effect

estimate

Adjusted effect

estimate

Has clients who have ever

injected drugs

0.5 (0.4–0.8) NS

Ever injecting drugs 0.2 (0.1–0.3) NS

Injected cocaine in the past

month

0.1 (0.01–0.5) 0.1 (0.01–0.6)

Sirotin, 2010

[90] (M)

Mexico Cross-

sectional, n =
474

Cis women

(street, bar)

Lack of registration at

the Municipal Health

Department

43.3 Unprotected sex 1.55 (0.94–2.57) 2.06 (1.21–3.50)

Ever injected drugs 1.43 (1.05–1.93) N/A

Quality appraisal definitions: H = high, M = moderate, L = low.

�STI symptoms in [74] defined as abdominal pain not relating to diarrhoea or menses, foul smelling vaginal discharge, pain while urinating, genital ulcers/sores,

swelling in groin area, or itching in last 6 months. STI symptoms in [72] defined as having genital/anal warts, genital ulcers or sores, genital itching, or abnormal vaginal

discharge in the past 6 months.
$STI/HIV defined as past infection with HIV or Treponema pallidum or acute infection with chlamydia or gonorrhoea [67].
&Physical violence defined as reporting 1 or more of the following: robbed, hit, beaten, threatened, attacked with a weapon, or kidnapped [67]

��Perpetrator of violence includes partner, pimp, dealer, police, security guard, stranger, or other but excludes clients.
¥Socias et al 2015: Recent prison is presented as the outcome in the original analysis but as temporal associations were not measured the outcomes and exposure

variables have been inverted for the review in order to facilitate comparison.
�Unmet health need defined as sometimes, occasionally, or never getting healthcare services when you need them versus always or usually getting them [61].
#Subotnik is defined as sex demanded by police in exchange for leniency towards pimps and female sex workers in past 3 months [73].

^Includes gonorrhoea, syphilis, and chlamydia [73].
\Physical violence defined as ever having been violently pushed, shoved, slapped, hit, kicked, choked, or otherwise physically hurt. Sexual violence defined as ever

having experienced forced sex through physical force, coercion, or penetration with an object against one’s will [68].

^^HIV prevention package included condom distribution, community-based methadone maintenance treatment and/or needle and syringe programme, and peer HIV/

AIDS education [80].
+Emotional ill health defined as reported diagnosis of depression, post-traumatic stress disorder, anxiety, schizophrenia, borderline personality, attention deficit, or

bipolar disorder within last 6 months [63].

HCV, hepatitis C virus; N/A, not available; NS, not significant; PHQ-2, Patient Health Questionnaire–2; RCT, randomised control trial; STI, sexually transmitted

infection.

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clinic (OR 1.74, 95% CI 1.02–2.98, p = 0.04) [71]. Confiscation of needles/syringes in Mexico

by the police was associated with increased odds of having an HIV test among sex workers

who inject drugs (OR 1.49, 95% CI 1.09–2.05, p-value not reported) [63]. In Canada, fear of

Fig 2. Meta-analyses summarising associations between repressive policing actions on HIV and sexually transmitted infections. RE, random effects; STI,

sexually transmitted infection.

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police and police harassment, including arrests, was associated with avoiding healthcare ser-

vices among street-based cis women [85] and cis and trans women [61]. Geospatial analyses

among the same population showed that a higher density of police enforcement practices

Fig 3. Meta-analyses summarising the association between repressive policing actions and sexual/physical violence from clients, intimate partners, and others.

Shannon, 2009 refers to [58]. RE, random effects.

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(including displacement, legal restrictions of sex work areas, and police harassment) was asso-

ciated with disrupted HIV treatment [56]. In Uganda, rushed negotiations with clients due to

police presence was associated with less frequent dual contraceptive use (OR 0.65, 95% CI

0.42–1.00, p = 0.05) [83]. In a study in China, where HIV testing is mandatory following deten-

tion, history of arrest was associated with increased odds of having an HIV test or taking up

HIV prevention interventions, but fear of arrest was associated with decreased odds of both

HIV testing (OR 0.78, 95% CI 0.55–1.12, p = 0.18) and accessing prevention interventions (OR

0.39, 95% CI 0.22–0.68, p< 0.001) [80]. Emotional ill health. Three studies looked at indicators of emotional ill health. In India, cis female sex workers mostly working on the street who had been arrested had increased odds of major depression (defined through Patient Health Questionnaire–2) (OR 1.6, 95% CI 1.1– 2.3, p = 0.05) compared to those who had not been arrested [88]. In Canada, recent incarcera- tion was associated with poor emotional health outcomes among both cis and trans female sex workers in a univariable analysis (OR 1.55, 95% CI 1.12–2.14, p< 0.10) [60]. Among the same population, individuals who reported that the police had affected where they worked had increased work stress compared to those who did not report this [55]. Fig 4. Meta-analyses summarising the association between repressive policing actions and condomless sex with clients and intimate partners. RE, random effects. https://doi.org/10.1371/journal.pmed.1002680.g004 Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 20 / 54 https://doi.org/10.1371/journal.pmed.1002680.g004 https://doi.org/10.1371/journal.pmed.1002680 Drug and alcohol use. Five studies examined the association between repressive policing practices and drug use including injecting drug use [60,66,86,87], the use of non-prescription opioids [27], and excessive alcohol drinking [60,66]. All of these studies showed a positive association between exposure to repressive policing practices and drug/alcohol use. One study among cis female sex workers in Mexico who inject drugs found a positive association between police confiscation of needles/syringes and injecting in public places (linked to increased risk of skin and soft tissue injuries but reduced risk of overdose) (OR 1.6, 95% CI 1.1–2.4, p-value not reported), as well as injecting in the groin area (linked to increased risk of overdose) (OR 1.9, 95% CI 1.2–2.9, p-value not reported), but reduced odds of injecting with clients (poten- tially linked to sharing needles/syringes but reduced risk of overdose) (OR 0.64, 95% CI 0.44– 0.94, p-value not reported) [63]. Another study with the same population found that confisca- tion of needles/syringes was associated with lower safe injection self-efficacy at 8 months (−0.51, SE 0.25, p = 0.04) [62]. Recent history of incarceration was associated with use of crys- tal methamphetamine among cis female sex workers in Iran [86]. Registration at a municipal health service. Four studies reported associations between mandatory registration at a city health service in Tijuana, Mexico and health outcomes [79,81,89,90]. One study suggested that registered sex workers had reduced odds of working in a sex work venue with high prevalence of HIV or syphilis and testing positive for HIV or an STI (syphilis, gonorrhoea, or chlamydia) univariably. These associations became insignificant after adjusting for injecting risk behaviours, age, and time in sex work [79]. Of note, sex work- ers who test positive for HIV in this system have their registration revoked, and sex workers already living with HIV cannot work in the regulated sector; therefore, sex workers who know or suspect they are living with HIV are unlikely to register. Registered sex workers had reduced odds of ever injecting drugs and higher odds of being tested for HIV [81]. A final study sug- gested that lack of registration was associated with increased odds of unprotected sex (OR 2.1, 95% CI 1.2–3.5, p-value not reported) [90]. Evaluation of sex work policies. Two studies in Canada evaluated a new policing guide- line that prioritised enforcement of laws against clients and third parties over arrest of sex workers introduced in Vancouver in 2013. These studies found that there was no decrease in physical and sexual violence (OR 1.09, 95% CI 0.59–2.04, p = 0.78) among participants sur- veyed after 2013 compared to those surveyed before, but there was increased report of rushed negotiations with clients due to police presence (OR 1.73, 95% CI 1.03–2.90, p-value not reported) [57,92]. The introduction of an anti-trafficking policy in South Korea, accompanied by brothel closures, in 2010 was associated with a decrease in prevalence of gonorrhoea and antibodies to Treponema pallidum (indicating current or past infection), but also changes in the demographic profile of sex workers. Sex workers were younger in surveys conducted after the act compared to before, which may contribute to the lower prevalence of infection, although sex workers reported receiving more clients [77]. Qualitative synthesis Included qualitative studies. From the 94 eligible papers including qualitative data, we generated 4 core analytical categories over 37 unique analyses (papers) in different legislative frameworks and geographical settings, refining these through the inclusion of a further 9 pur- posively sampled papers (S3 Text). Studies were undertaken in a range of legislative models: Full criminalisation models were represented in 3 papers in the US; 2 papers each in Cambo- dia, Kenya, Serbia, South Africa, and Sri Lanka; and 1 paper each in Australia, China, Nepal, Pakistan, Uganda, and Zimbabwe. Partial criminalisation models were represented in analyses from 5 papers in Canada and 1 paper each in Hong Kong, India, Nigeria, Thailand, and the Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 21 / 54 https://doi.org/10.1371/journal.pmed.1002680 UK. Five papers focused on Canada following the introduction of criminalisation of clients, and 1 on Sweden, where that model is in place. Regulatory models—which criminalise those non-compliant with regulations including tolerance zones, regulated venues, and/or manda- tory registration at a health care facility—were represented by 2 papers each from Australia, Guatemala, Mexico, and the US and 1 from Turkey. Four papers related to New Zealand, where sex work has been decriminalised. In total, interviews with 2,199 sex workers were ana- lysed, representing a range of sex work locations (including street settings, truck stops, broth- els, massage parlours, bars, night clubs, hotels, lodges, and homes) and means of meeting clients (including organised in person, via phone or online, independently, and via third par- ties). Most studies focused on cis women exclusively (n = 25), with a minority including sub- samples of trans women or transfeminine people (n = 18) or cis men (n = 9). Just 2 papers focused exclusively on the experiences of trans sex workers, and 1 on male sex workers. Ten studies included interviews with other actors associated with sex work, including clients, venue managers/owners, police, and outreach workers, but our analyses focused on data from sex workers themselves. Characteristics of included studies (data-rich and purposively sam- pled) [22,26,34–36,49,93–132] are summarised in Table 3, indicating which papers were pur- posively selected. A list of the other papers that were identified but not included is available (S3 Text). Core analytical categories identified include disrupted workspaces and safety strategies; institutionalised violence, coercion, and extortion, and restricted access to justice; reproduc- tion of multiple stigmas and inequalities; and restricted access to health and social care and support (S4 Text). Illustrative quotes from the core categories are summarised in Box 1. Core category 1: Disrupted workspaces and safety strategies. In contexts of full or par- tial criminalisation, laws against soliciting or communication in public places for the purpose of prostitution—and feared or actual arrest—compromised street-based sex workers’ safety by rushing or displacing client screening and negotiations to secluded places, resulting in greater vulnerability to violence and theft by clients and others (Quote 1) [22,98,121,122,125,130]. For sex workers operating indoors, these laws impeded direct negotiations with clients and com- munication between peers about safety and sexual health [121]. This pattern persisted in con- texts where clients were criminalised. Since it was in clients’ and sex workers’ mutual interest to avoid police detection, and because increased police presence and reduced number of cli- ents led to the need to work longer hours [34,114], sex workers limited, rushed, or forewent usual client screening and negotiation, and were displaced to more isolated areas, increasing their exposure to violence and sexual health risks (Quotes 2, 3, 4a, and 4b) [34,114]. In Canada, cis and trans female sex workers continued to be displaced by police in areas undergoing gen- trification, and, even when they were not targeted, some still experienced police presence as harassment [26,114]. Across diverse contexts, experience of possession of condoms being used as evidence of sex work, and experience of police raids where condoms had been confiscated, led to sex workers not carrying, using, or accessing condoms consistently [93,98,106,109] and venues restricting or not providing them [93,98,109,118]. In South Australia, sex workers attributed the latter to increased raids, closures, and the recent arrest of a venue owner [98]. Laws against brothel-keeping and bawdy houses left sex workers in the UK [123] and Can- ada [102,121] having to choose between working safely with other sex workers and/or third parties (e.g., security guards and drivers) and avoiding arrest by working in isolation (Quote 5), and deterred venue managers from providing sexual health training and supplies [93,121]. A lack of legal protection left sex workers vulnerable to exploitation by venue managers who could restrict access to information on their working and legal rights [121,123]. Anti-trafficking policies in Cambodia and attempts to ‘eliminate’ sex work in China resulted in police crackdowns on brothels, which displaced sex workers to unfamiliar and Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 22 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. Summary of qualitative study characteristics included in the thematic analysis including legislative context and methods. First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Abel, 20141 [36] New Zealand (various) Full decriminalisation. All aspects of adult sex work decriminalised in 2003. Condom use required by law. To present aspects of New Zealand’s experience with sex work decriminalisation, discussing process to get decriminalisation on policy agenda, way legislation was implemented, and impact on sex workers and wider community 58 sex workers (47 cis women, 9 trans people2, 2 cis men); aged 18–55 years. Ethnicities not reported. Main current sector: street, managed, private (most had worked in another sector in past). Recruited via sex worker organisation, by phone, and in sex work areas; maximum diversity sampling. In-depth interviews and focus groups (within mixed-methods study). Thematic analysis. Members of sex worker organisation helped to develop interview guide and interpret data. Impact of the Prostitution Reform Act, relationship with police and access to services. Anderson, 2016 [93] Vancouver, Canada Criminalisation of indoor venues and third parties. In-call venues were subject to police raids, city inspections, licensing requirements, fines and license revocations, and enforced closures. National laws against operating a ‘bawdy house’ (i.e., sex work venue) and living off income generated via sex work were ruled unconstitutional during fieldwork. Not stated, but the study is located within a community-based research project that aims to investigate the physical, social, and policy environments shaping sex workers’ sexual health, violence, HIV/STI risks, and access to care. Authors also stress the ‘need for research on the health and safety impact of sex work laws that criminalise managers and other third party actors who work in in- call sex work establishments’. 46 participants: 23 sex workers, 23 managers/owners (15 both workers and managers/owners). 45 cis women, 1 cis man (manager/ owner). All migrants of Asian origin. Median age: 42 years (IQR 24–54). Recruited via outreach to in-call sex work venues and online. Semi-structured interviews. Ethnographic observation (>430

hours) of physical and

social aspects of indoor

sex work environments.

Thematic analysis (a

priori and inductive).

Research team included

sex workers.

Experiences in the sex

industry; interactions

with police, city

officials, co-workers,

managers, and

owners; and access to

condoms, education,

training, and outreach

services.

Armstrong,

2014, 2015,

2016 [94–96]

Wellington and

Christchurch, New

Zealand

Full decriminalisation. All

aspects of adult sex work

decriminalised in 2003.

Condom use required by

law.

To examine how the

decriminalisation of sex

work impacts on

violence risk

management.

28 cis female sex

workers, aged 17–57

years. Main current

sector: street. 15

women identified as

Maori (including 1

Cook Island Maori),

13 as New Zealand

European. Recruited

via sex worker

organisations. 17 key

informants working

in agencies to support

sex worker safety.

In-depth semi-

structured interviews,

observation. Analysis

methods not described.

Entry into sex work,

perceptions of risk,

experiences of

violence, strategies to

manage risk, and

impacts of the 2003

change in legislation.

(Continued)

Health impact of sex work legislation

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 23 / 54

https://doi.org/10.1371/journal.pmed.1002680

Table 3. (Continued)

First author,

year

[reference]

Setting Legislative model and

policing�
Aim of study/article Participants and

recruitment

Methods Focus of interviews/

analysis

Benoit, 2016

[97]

Canada (6 cities) Partial criminalisation.

Exchange of sexual services

legal, but related activities

illegal.3

Part of multi-project,

community-engaged

study examining

perspectives and

experience of 5 groups

directly and indirectly

affected by the sex

industry. This paper

focuses on sex workers’

perceptions and

experiences with the

police, to provide

baseline data to assess

the impact of legal

change on sex workers’

confidence in police.

139 sex workers: 77%

identified as women,

17% as men, 6% as

other gender

identities (including

trans women and

trans men). Mean

age: 34 years (all 19

or older), 19%

identified as

indigenous, 12% as

‘visible minority’

(other ethnicities not

reported). 22%

worked on street,

54% indoors, and

24% in managed

indoor work.

Participants had to

have right to work in

Canada. Maximum

diversity sampling.

Open-ended questions

within structured

interviews. Thematic

analysis.

Interactions with

police through sex

work, perceptions of

police attitudes,

intersectional

discrimination, and

enhanced feelings of

safety or danger.

Baratosy,

2017 [98]

Adelaide,

Australia

Partial criminalisation.

Criminalised activities

include soliciting or

loitering in public places;

receiving money or being

present in a brothel; and

managing, keeping, or

assisting to manage a

brothel. In 2015 a

decriminalisation bill was

brought before parliament.

To explore the lived

experiences of South

Australian sex workers

working within a

criminalised setting to

contribute evidence

supporting

decriminalisation in the

South Australian

context.

10 sex workers (7 cis

women, 1 trans

woman, 1 cis man, 1

gender-queer). Aged

31–68 years, working

mostly off street (1

participant worked

on street). Ethnicities

not reported.

Participants recruited

via sex-worker-led

peer support and

education

organisation.

Semi-structured

interviews. Thematic,

iterative analysis with

reflections on

researchers’ influence

on interview. Sex

worker involvement in

study design.

Experience of sex

work: police

involvement,

workplace protection,

and health.

Biradavolu,

2009 [99]

Rajahmundry,

India

Partial criminalisation. Act

of selling sex not illegal, but

promoting or profiting

from sex work and all

associated activities that

make sex work possible are

illegal.

To evaluate a

community-led

structural intervention

for HIV prevention

among sex workers

(community

mobilisations, changes

in policing,

establishment of

community-based

organisations).

75 cis female sex

workers mostly

working from home

or street. Age and

ethnicity not

recorded.

Participants recruited

via outreach and

through NGO. 11

interviews with NGO

staff and 36 with

lawyers, police, and

other actors

associated with sex

work.

Interviews, observations

of NGO meetings.

Thematic analysis.

Involvement in

intervention, law,

policing, and policy

environment of sex

work in

Rajahmundry, and life

histories.

(Continued)

Health impact of sex work legislation

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 24 / 54

https://doi.org/10.1371/journal.pmed.1002680

Table 3. (Continued)

First author,

year

[reference]

Setting Legislative model and

policing�
Aim of study/article Participants and

recruitment

Methods Focus of interviews/

analysis

Brents, 2005

[100]

Nevada, US Regulation. Licensed

brothel system in counties

with population< 400,000, with mandatory regular HIV and STI testing. Out- calls legal in certain counties, illegal in others. Illegal to live off earnings of sex work or coerce someone into sex work. To examine the issue of violence within legalised brothels and analyse the mechanisms in brothels that address safety and inhibit risk of violence. 25 cis female sex workers recruited from 4 legalised brothels. Age and ethnicities not reported. 11 former brothel managers and owners, 10 activists, and 5 brothel customers also interviewed. Semi-structured interviews, ethnographic observation of public debates. Thematic analysis. Analysis focused on safety, violence, danger, risk, and fear. Cepeda, 2014 [101] Nuevo Laredo and Ciudad Juarez, Mexico Regulation. Sex work legal in tolerance zones; registration, weekly HIV/ STI testing, and valid health card mandatory. Illegal in all other areas. To describe violence that sex workers experience and to understand the role of contextual constraints (e.g., venues, geographical context, gender system). 109 cis female sex workers, aged 18–46 years. All Mexican nationals (ethnicities not reported). Mapped then randomly selected locations/venues— included bars, clubs, hotels, dance bars, and street. Recruitment by outreach workers from local community. Life history interviews. Grounded theory analysis (open then selective coding). Demographics, career trajectory, clients, drug use, sexual behaviour, and HIV/ AIDS. Corriveau, 2014 [102] Toronto, Ottawa, and Montreal, Canada Partial/quasi criminalisation. Exchange of sexual services legal, but related activities illegal3; body rub parlours and low- barrier supportive housing unsanctioned. To understand the experiences and views of adult male escorts of (1) criminal law relating to sex work and (2) strategies to cope with the legal situation. 19 cis male sex workers, all working as escorts, independently in clients’ homes or hotels; aged 19–41 years; majority (15) white Canadian, other ethnicities not reported. Recruitment via social and professional networks and flyers. Semi-structured interview. Analytical methods not described. Work experience and ambiguity of criminal law relating to sex work, and strategies used to cope with dangers of current legal climate. Dewey, 2014 [103] Denver, US Full criminalisation. Selling and buying sex illegal. Location of first ‘end demand’ initiative in US in 1994—targeting clients of sex workers via intensified policing of street sex work locations. To explore normative beliefs and practices that inform women’s decision-making processes as they interact with or seek to avoid police. 50 cis women working on the street, aged 18–63 years, majority African American, fewer identified as white, Latina, and Native American. Recruitment via snowball sampling. Open-ended interview. Thematic analysis. Ethnographic approach (researcher lived in street sex work area to get to know participants). How women define coercion in their everyday work experiences; women’s help-seeking practices and, within that, how they interact with police and social services. Ediomo- Ubong, 2012 [104]† Ikot Ekpene, Nigeria Partial criminalisation. Criminalised activities include ownership or management of a brothel, underage sex work, and living off proceeds of sex work. To understand experiences and decision-making in relation to drug use as a risk behaviour in life and work. 86 cis female sex workers working in brothels, identified through systematic sampling following mapping of all brothels in the area. Age and ethnicities not reported. Focus groups and in- depth interviews. Textual and thematic analysis. Drug use, factors motivating drug use, and effects on lives and work. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 25 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Foley, 2010 [105] Dakar, Senegal Regulation. Registered sex workers allowed to work legally (only cis women are eligible). Registration requires twice-monthly screening at STI clinic and presentation of health card; individuals’ details are sent to police. Public solicitation is illegal. Only 20% of sex workers are registered. To identify key features of Senegal’s national HIV/AIDS policies and programmes. 60 registered and unregistered cis female sex workers, some of whom are living with HIV. All recruited via local NGO working with sex workers. Age and ethnicity not recorded. 10 government officials, physicians, NGO directors, and civil society leaders also interviewed. 4 community dialogue sessions with sex workers. Semi- structured interview guide for other participants. Content analysis. Knowledge of HIV transmission, HIV/ AIDS programmes, and ideas about vulnerability to HIV. Ghimire, 2011 [106]† Kathmandu Valley, Nepal De facto full criminalisation. No legislation around sex work, but anti-trafficking laws used to regulate sex work and many policies used against sex workers. To present individual, structural, and cultural factors facilitating or creating barriers to use of condoms among sex workers. 15 cis female sex workers, aged 19–42 years, purposively selected from a survey of 425 sex workers to represent diversity of ages, ethnicities, and marital and socio- economic statuses, working across a range of settings (restaurants, street, massage parlour). Majority were Janajati (ethnic minority group). In depth interviews. Thematic analysis. Knowledge and use of condoms, sexual activities and protective behaviour, potential partners, sexual harassment, and characteristics of partners. Goldenberg, 2018 [132] Tecún Umán, Guatemala Regulation. Licensed indoor establishments with mandatory HIV/STI testing and health permits and informal street and indoor locations (hotels, motels, bars). To examine the ways in which intersecting features of indoor work environments influence safety and agency to engage in HIV/STI prevention. 39 cis female migrant sex workers from Honduras, El Salvador, Nicaragua, Mexico, or Guatemala. Median age 27 years, working in formal venues with a health permit (27) and informal venues (17). Recruitment via community-based team of outreach workers with purposive sampling to ensure diverse range of migration experience. Ethnographic: observations, focus groups, and in-depth interviews. Thematic analysis. Research guided by community advisory board of sex work, HIV, and women’s organisations. Sex work and migration histories, working conditions, interactions with police and immigration and health authorities, violence, HIV/STIs, health service access, and other health concerns. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 26 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Gulcur, 2002 [107]† Istanbul, Turkey Regulation. Licensed brothels, with mandatory registration of sex workers including regular STI checks and ID cards. The systems is only for Turkish citizens. To document the experience and working conditions of women who travel to Istanbul to undertake sex work. 3 cis female migrant sex workers from Eastern Europe and former Soviet Union countries (ages not reported) and 6 key informants (clients, sales people, and bartenders). Recruitment via hotels, bars, and businesses in district where sex work takes place. Unstructured interviews. Thematic analysis. Experiences and working conditions of migrant women as well as local discourses and attitudes surrounding migrant sex workers. Ham, 2014 [108] Melbourne, Australia Regulation. Licensing framework for legal brothels and independent workers (Sex Work Act 1994), who are required to register and obtain licence. Medical certificate (STI screen) is required every 6 weeks. To understand how sex workers’ agentic use of ‘strategic invisibility’ is affected by Melbourne’s sex work legalisation framework. 55 sex workers, mostly cis women (6 cis men, 2 trans women), working independently, as escorts, or in brothels. Majority white Australian, but 17 identified as South East Asian, English, Eastern European, or New Zealander. Participants recruited through fliers and email lists. Open-ended interviews. Thematic analysis around key themes of stigma, health and well- being, and working conditions. Working conditions. Handlovsky, 2012 [109]† Vancouver, Canada Partial/quasi criminalisation. Exchange of sexual services legal, but related activities illegal3; body rub parlours and low- barrier supportive housing unsanctioned. To investigate how condom use is practiced in massage parlours and as a social phenomenon situated within the nexus of supports and constraints. 21 individual and group interviews with cis female sex workers working in massage parlours. Mean age 30 years, 11 migrants from Asia. Recruitment via community outreach. Conversational interviews. Thematic analysis. Sex workers involved as community researchers in linked survey (not reported if involved in qualitative component). Condom use practices in commercial sex exchanges and personal, interpersonal, and structural level factors that influence use. Huang, 2014 [110]† China (6 cities and counties) Full criminalisation. Criminalisation of purchase and sale of sex. Periodic crackdown on sex work with aim to eradicate sex work, as happened in 2010. To explore strategies that female sex workers and managers adopted to deal with the 2010 police crackdown; discussion of the implications for health and HIV-related risks. Interviews with 107 cis female sex workers. Ages and ethnicities not reported. 26 managers of sex work establishments, 13 outreach workers, and 24 health providers. Sex workers recruited through NGOs and sex work sites including hair salons, massage parlours, and street-based locations. Observation and interviews. Thematic analysis. Effects of police practices following the 2010 crackdown and strategies used in response. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 27 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Karim, 1995 [111]† Truck stop mid- way between Durban and Johannesburg, South Africa Full criminalisation. Criminalisation of purchase and sale of sex. To explore the social context of risk of HIV infection. Interviews with 10 cis female sex workers at truck stop, aged 17– 34 years, all black (ethnicities not reported). Recruited via sex worker from setting trained in research methods. 9 interviews with truck drivers. Interviews, field notes. Content analysis. Social conditions at truck stop, sex work, family history, attitudes, and practices towards HIV/AIDS. Katsulis, 2010 [35] Tijuana, Mexico Regulation. Sex work legal in tolerance zones; registration, weekly HIV/ STI testing, and valid health card mandatory. Illegal in all other areas. To examine the social context of workplace violence and risk avoidance in the context of legal regulation meant to reduce harms associated with sex work. 190 cis female sex workers recruited through STI clinics and in bars, clubs, and street settings, using snowball sampling following a mapping of sex work areas. Mean age 26 years, ethnicities not reported. Other interviews included police (4), hotel and bar owners (7), medical personnel (13), and community health outreach workers (23). Ethnographic research included field observations and interviews. Grounded theory and thematic analysis. Experience and management of violence at the hands of customers, strangers, and police. Kiernan, 2016 [112]† Goma, DRC Partial/quasi criminalisation. Exchange of sexual services legal, but related activities illegal including forced sex work, but little government enforcement in reality. To explore the experience of urban sex workers in eastern DRC in relation to violence, barriers to medical care, and use of local resources. 7 cis female and 1 cis male sex workers working in a night club, aged 23–34 years. Ethnicities not reported. Convenience sampling. Semi-structured interviews. Thematic analysis. Characteristics of sex work, exposure to violence, available resources, and access to medical care. Krusi, 2012 [113] British Columbia, Canada Partial/quasi criminalisation. Exchange of sexual services legal, but related activities illegal3; body rub parlours and low- barrier supportive housing unsanctioned. To report experiences of sex workers living and working in low-barrier supportive housing, focusing on how environments influence sex workers’ safety and risk negotiation with clients. 39 sex workers (38 cis women, 1 trans woman) living and working in low- barrier supportive housing. Aged 22–58 years (average 35), 30 of Aboriginal ancestry, 2 ‘other visible minorities’, 7 white. Recruited via 2 housing programmes. In-depth interviews and focus groups. Content analysis. Focus groups co-facilitated by sex workers. Experiences of living and working in low- barrier supportive housing, rules and regulations, police and staff relationships, safety, and negotiation. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 28 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Krusi, 2014 [114] Vancouver, Canada De facto criminalisation of clients. New police guidelines (2013) prioritised sex workers’ safety over enforcement, but continued to arrest clients. To evaluate how enforcement against clients, but not sex workers, shapes sex workers’ interactions with police, negotiation of working conditions and transactions with clients, and protection against violence and HIV/STIs. 31 cis and trans female sex workers, aged 24–53 years. 8 of Aboriginal ancestry, 2 ‘other visible minorities’, 21 white. All had worked on street; now mainly sought clients on street (24) or by phone (7); provided services in vehicles/ outdoors (27) or informal indoor venues (14). Purposive sampling via existing cohort study representing diversity in age, ethnicity, gender, and work environments. Semi-structured interviews. Ethnographic observation of street sex work areas. Thematic analysis. Research and outreach team included sex workers. Working conditions, interactions with police, and negotiations of health and safety with clients. Krusi, 2016 [26] Vancouver, Canada De facto criminalisation of clients. New police guidelines (2013) prioritised sex workers’ safety over enforcement, but criminalised the purchase of sex, benefiting from the proceeds of sex work in an ‘exploitative’ fashion, advertising sexual services, and communication for the purpose of selling sexual services. Part of a larger longitudinal qualitative and ethnographic study (AESHA) investigating how the physical, social, and policy environments shape working conditions and health of sex workers. This study aimed to explore the complex ways in which stigmatising assumptions of sex workers as ‘risky’ and ‘at risk’ intersect with evolving sex work policing strategies to shape street-based sex worker rights, experience of violence, and negotiation of sexual risk reduction. 31 sex workers (26 cis women, 5 trans women). Mean age 38 years; 8 of indigenous ancestry, 2 ‘other visible minorities’, 21 white. All had worked on street; now mainly sought clients on street (24) or by phone (7); provided services in vehicles/ outdoors (27) or informal indoor venues (14). Purposive sampling via existing cohort study representing diversity in age, ethnicity, gender, and work environments. Semi-structured interviews. Inductive and iterative thematic analysis, drawing on concepts of structural vulnerability, structural stigma, and everyday violence. Sex workers were involved in advising on the research. Police interactions, working conditions, and negotiation of sex work transactions with clients after implementation of new policy. Levy, 2014 [34] Sweden (various) Criminalisation of clients. In 1999, purchase of sex was criminalised and sale of sex decriminalised, but brothel- keeping charges remain. Discusses the impact of Swedish sex purchase law on levels of sex work, sex work displacement, increasing dangers and difficulties of some types of sex work, service provision, and disruption of sex workers’ lives. 26 sex workers (22 cis women, 2 trans people2, 2 cis men); cis women working on street or as escorts, or stripping. Ages and ethnicities not reported. Also interviewed: clients, service providers, activists, police, and policy-makers. Recruited via public places, organisations attended by sex workers, and social networks. Ethnographic participant observation and interviews. Grounded theory analysis. Co-author founded national sex worker rights organisation. Not specified (see aim). (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 29 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Lutnick, 2009 [115] San Francisco, US Full criminalisation. Selling and buying sex illegal. Proposal to decriminalise sex work, supported by Public Health Department and community groups, defeated in 2008. To investigate the perspectives and experiences of a wide range of cis female sex workers regarding the legal status of sex work and the impact of the law on their working experiences. 40 cis women working in street and off-street settings. Average age 41 years; 18 African American, 16white, 3 Latin American, 2 Asian/ Pacific Islander, and 1 Native American. Recruited through community-based organisations. Semi-structured interview. Grounded theory analysis. Former and current sex workers involved in all aspects of study, including design, implementation, analysis, and write-up. Social context of sex work, experiences with law enforcement, what work would be like if prostitution was not a criminal offence, and ideal legal framework for sex work. Lyons, 2017 [116] Canada, Vancouver De facto criminalisation of clients. New police guidelines (2013) prioritised sex workers’ safety over enforcement, but continued to arrest clients. To investigate the lived experience of violence and social-structural (social, political, and legal) contexts shaping violence among trans sex workers. 33 trans female sex workers, aged 23–52 years, 23 of indigenous origin, 7 white, 3 Filipino, Asian, or ‘other visible minority’. Majority worked on the street. Recruited via existing cohort. In-depth interviews. Theory- and data- driven participatory analysis guided by ‘risk environment’ and ‘structural determinants’ framework. Sex workers were involved in the analysis. Analysis focuses on how transphobia and criminalisation shape violence. Key themes: transphobia, clients’ discovery of gender identity, and negative police response to violence. Maher, 2011 [117] Phnom Penh, Cambodia De facto full criminalisation. In 2008, trafficking law criminalised most aspects of sex work3; effectively made sale and purchase of sex illegal, led to police crackdowns and brothel closures. To explore the relationship between sex work contexts and conditions and vulnerability to HIV/ STI and related harms. 33 cis women aged 15–29 years working in brothels, entertainment venues, streets, and parks recruited through neighbourhood outreach by local NGO. Ethnicities not reported. Inductive analysis drawing on principles of grounded theory. Initiation into sex work, experience of sex work, conditions of sex work, drug and alcohol use, and culture and orientation towards prevention and use of HIV/STI services. Maher, 2015 [118] Phnom Penh, Cambodia De facto full criminalisation. In 2008, trafficking law criminalised most aspects of sex work4; effectively made sale and purchase of sex illegal, led to police crackdowns and brothel closures. To explore the impact of the 2008 trafficking law on sex workers’ HIV vulnerability and right to health. 80 interviews with cis female sex workers, aged 15–29 years, working in brothels, entertainment venues, streets, and parks. Ethnicities not reported. Recruited via community partner organisation (sampling methods not defined). In-depth interviews. Iterative, inductive analysis guided by grounded theory. Wave 1: impact of law and police crackdowns was a key emerging theme. Wave 2 (2011): impact of law on women’s lives. Mayhew, 2009 [119]† Rawalpindi and Abbottabad, Pakistan De facto full criminalisation. Criminalisation of purchase and sale of sex, and third party making profits from sex work. Homosexuality illegal. To investigate the nature and extent of human rights abuses against sex workers, transgender individuals, and people who inject drugs. 38 respondents (PWID, trans people, and sex workers) recruited through local NGO. Age and ethnicities not reported. Participatory ethnographic and evaluation research, training peers to conduct interviews. Thematic analysis. Complexities of gendered and sexual identities and nature and scale of abuse suffered. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 30 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Miller, 2002 [120] Colombo, Sri Lanka De facto full criminalisation. Criminalisation of purchase and sale of sex, and third party making profits from sex work. Lodges and massage clinics licensed, but sex work practiced covertly. Homosexuality illegal. To investigate the routinization of violence and harassment against women and transgendered/gay men in an illegal sex market. 160 sex workers (107 cis women, 27 trans people, 26 cis men) recruited through snowball sampling and working across a range of settings (street, brothels, massage clinics). Age and ethnicities not reported. Also interviewed other people connected to sex industry (50) (e.g., managers, taxi drivers), clients (50), and criminal justice practitioners and NGO staff (15). In-depth interviews. Thematic analysis around topic guide. Relationship between cultural definitions of gender/sexuality and the implementation of existing legal frameworks, and impacts on treatment and experiences of sex workers. Nichols, 2010 [49] Colombo, Sri Lanka Full criminalisation. Vagrants Ordinance penalises sex workers, third parties (and clients)5. Homosexuality illegal since colonial era; with rise in sex tourism, law increasingly targets male sex workers. To examine how ‘gender and sexual orientation intersect to create unique configurations of abuses’ against transgender sex workers, compared with female sex workers. 24 interviews and 3 focus groups with transfeminine (‘nachichi’) sex workers, aged 18–42 years, working predominantly on street. Ethnicities not reported. Recruited by interviewers, via outreach to sex work settings and snowballing. In-depth interviews and focus groups. Inductive, intersectional analysis: open then selective coding, categorising types of police abuse. Background, education, employment, first sex, sex work, gender and sexual identity, and experiences with family, community, clients, and police regarding gender and sex work. O’Doherty, 2011 [121] Vancouver, Canada Partial/quasi criminalisation. Exchange of sexual services legal, but related activities illegal3; body rub parlours and low- barrier supportive housing unsanctioned. To share findings from research with off-street sex workers, focusing on their views of how criminal laws affect their work. 9 cis female sex workers, aged 22–44 years. None identified as Aboriginal or Métis (other ethnicities not reported). All independent; 8 had worked in other sectors in past (3 on street). Also interviewed 1 massage parlour owner/former sex worker. Recruited online (advertising on escort directory and secure website). In-depth interviews. Analysis methods not reported. Former and current sex workers collaborated on the research. Experiences of victimisation and work in indoor sex industry. Interviews identified common concerns and opinions about law. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 31 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Okal, 2011 [122] Naivasha and Mombasa, Kenya Full criminalisation. Many local authorities have specific bylaws against loitering or procuring for sex work or homosexuality. In Mombasa, consensual sex between men is criminalised. Often only sex workers, not clients, are taken to court for loitering or indecent exposure. To examine the social and legal contexts that underpin the high levels of sexual and physical violence that pervade sex work in Kenya. 8 focus group discussions with 10– 12 cis female sex workers aged 16–49 years, organised by natural groups, site of recruitment, and full/ part-time sex work; recruited through HIV/AIDS peer educators and snowball sampling. Ethnicities not reported. Focus group discussions. Content and thematic analysis. Work, health, and contraceptive use. Pitcher, 20142 [123] UK and Netherlands (various) Partial/quasi decriminalisation (UK). Regulation (Netherlands). Sex work through licensed brothels legal for consenting adults, but illegal for individuals under 18 years old and migrants. To compare the experiences of sex workers under different legal frameworks. 36 interviews with sex workers working in off-street venues, 2 managers, and 2 receptionists in massage parlours in UK (28 cis women, 9 cis men, 3 trans people). 30 identified as white UK, 6 as white European, 2 as white other, 2 as multiple ethnic groups. In-depth interviews (UK only), comparative analysis of sex workers’ experiences under 2 different policies. Thematic analysis. Experiences in sex work. Pyett, 1999 [124] Melbourne, Australia Regulation. Legal in licensed brothels; illegal elsewhere (including escorting6/street). Condom use mandatory in licensed venues. To explore issues of safe sex and risk management among sex workers who work on the street or in other criminalised sectors. 24 cis female sex workers, aged 14–47 years (average 28), working on street or in illegal brothels. Ethnicities not reported. Purposively sampled women perceived as potentially vulnerable.7 In-depth interviews. Content and thematic analysis. Sex workers involved in planning, recruitment, interviewing, and interpretation. Managing work services, safety, stress, condom use, and relationships; worries, plans, health, caring, support, relaxation, disclosure, relationships, and child care problems. Ratinthorn, 2009 [125] Bangkok, Thailand Partial criminalisation. Sex work allowed to operate in entertainment establishments, but street sex work is prosecuted under public nuisance and soliciting laws. To explore characteristics of violence against sex workers and how violence influences personal and societal health risks. 28 cis women working on the street recruited via purposive, theoretical, and snowball sampling to select participants who had experienced violence. Recruited in work settings in 3 districts. Average age 32 years, all born in Thailand. In-depth interviews, 1 focus group, observation of workplaces. Thematic analysis drawing on grounded theory techniques. Presence and consequences of work-related violence; how violence threatened participants’ health, lives, and families; and their response to it. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 32 / 54 https://doi.org/10.1371/journal.pmed.1002680 Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Rocha- Jiménez, 2017 [126] Tecún Umán and Quetzaltenango, Guatemala Regulation. Change in legislation: sex workers no longer required to carry a registration card but must continue regular HIV/STI testing. To explore how the implementation of public health practices (mandatory HIV/STI testing) shapes HIV prevention and care among migrant sex workers. 53 cis female sex workers, majority working in off-street venues. All participants Spanish- speaking with history of internal or cross- border migration. Average age 31 years. Recruitment via outreach and local NGO. Focus groups and in- depth interviews. Thematic analysis. Research guided by community advisory board that included female sex workers. Experiences with public health practices, related interactions with authorities (i.e., police), and HIV prevention and care. Scorgie, 2013 [127] Kenya, South Africa, Uganda, and Zimbabwe (various) Full criminalisation. However, municipal bylaws and non-criminal legislation (e.g., loitering, public nuisance, indecent exposure) typically used to arrest and detain sex workers because easier to enforce. To examine the combined effects of criminalisation and law enforcement on sex workers’ everyday lives and social relations and how they affect health and well-being. Cis women (106), cis men (26), and trans women (4) working in a range of sex work settings (street, bar, hotel, and home) recruited through the African Sex Worker Alliance and snowball sampling. Mean age 25 to 35 years across sites, approximately 25% had history of internal or cross- border migration. Ethnicities not reported. In-depth interviews and focus groups. Thematic analysis. Participatory approach: peer educators conducted interviews and checked analysis. Experience of human rights violations by police, clients, regular partners, landlords, and others involved in the sex industry. Shannon, 2008 [22] Vancouver, Canada Partial criminalisation. Purchase and sale of sex not illegal (at time of study), but laws against communicating and keeping a bawdy house (similar to soliciting and brothel-keeping laws, respectively). To explore the role of social and structural violence and power relations in shaping the HIV risk environment and prevention practices of women in survival sex work. 46 women (cis and trans), average age 34 years, 57% identified as of Aboriginal origin. Recruited via purposive sampling following social mapping led by sex workers. Focus groups. Thematic content analysis drawing on concepts of risk environment; structural, symbolic, and everyday violence; and relational notions of power. Participatory action research: survival sex workers involved in project conceptualization, implementation, and dissemination. How sex work defined, relationships with clients and partners, descriptions/ meanings of ‘bad date’ and safe environment, circumstances affecting power and control with clients, protective strategies, effectiveness of harm reduction services. Sherman, 2015 [128] Baltimore, US Full criminalisation. Selling and buying sex illegal. In 2000–2007, intensified policing in low- income, minority neighbourhoods, including street sex work areas. Specialist prostitution squads can legally solicit/ entrap sex workers. To explore interactions between police and sex workers in professional and personal lives, in relation to broader HIV risk environment. 35 adult cis female sex workers; median age 37 years; 20 identified as African American, 15 as white. Purposive and snowball sampling. Recruited via organisations working with sex workers on street, in dance clubs, and in drug houses and via social network referrals. In-depth interviews. Grounded theory analysis. Entry into sex work, current work, condom use and negotiation, substance use, experiences of violence, and police interactions. Relevant themes: police repeatedly disregarding women’s safety, verbal and sexual harassment, and entrapment. (Continued) Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 33 / 54 https://doi.org/10.1371/journal.pmed.1002680 sometimes isolated locations (e.g., the street, bars, massage parlours, and private accommoda- tions) where, working alone, they had less protection and control over negotiations with cli- ents, lacked peer support to establish collective norms on condom use (Quote 6a and 6b), and were more vulnerable to sexual and other violence both from police and perpetrators posing as clients [110,117,118]. In Guatemala, some venue managers warned sex workers about raids, Table 3. (Continued) First author, year [reference] Setting Legislative model and policing� Aim of study/article Participants and recruitment Methods Focus of interviews/ analysis Rhodes, 2008, and Simic, 2009 [129,130] Belgrade and Pancevo, Serbia Full criminalisation. Criminalised under article 14 of the Law of Peace and Order. To explore sex workers’ perception of HIV risk environment in Serbia. 24 cis women and 7 trans women working mostly in street sex work (beside busy roads, at railway and bus stations, at busy hotels) but some working via newspaper ads and in clubs/bars. Average age 28 years; 15 participants Roma (including all trans women, all working on the street), other ethnicities not reported. Recruitment via outreach services and snowballing. Semi-structured interviews. Data collected in 2 waves to enable provisional coding and inform purposive sampling. Thematic analysis. Entry into and modes of sex work, condom use and access, drug use, risk management, HIV and STI prevention, and health service need. Main themes: violence from police and clients, moral policing, and non- physical violence. Wong, 2011 [131]† Hong Kong Partial criminalisation. Act of selling sex not illegal, but soliciting, keeping an establishment, or living on earnings of sex work is illegal. To identify ways in which stigma may affect sex workers and how this links to health. 48 cis women selling sex working in a variety of venues (nightclubs, karaoke bars, brothels, and street) recruited through local NGO. Age not specified, 34 originated from Thailand, Philippines, Vietnam, or mainland China and 14 from Hong Kong. In depth interviews. Data collection and analysis informed by grounded theory approach employing content analysis methods. Experience and negotiation of sex- work-related stigma. �Legislation and policing refers to at the time of the research. †Papers purposively selected to reflect populations, settings, legislative models, and/or health issues under-reflected in the synthesis. 1For any methodological details not included in the paper, we retrieved this information from the original PhD thesis upon which the paper was based. 2Paper doesn’t specify whether trans women or trans men. 3Activities criminalised included communicating for prostitution in public spaces, procuring or living off the avails of prostitution, and keeping a bawdy house (i.e., brothel-keeping). 4Including public soliciting, procurement, managing a prostitution establishment, and providing premises for prostitution. 5Vagrants defined to include ‘those that engage in public loitering and prostitution’ including ‘aiding, abetting, or compelling a prostitute’. 6Escort agencies have since become eligible to register legally with the Prostitution Control Board, but were still criminalised during data collection. 7Considered vulnerable if young, inexperienced, homeless, drug or alcohol dependent, or working in illegal brothels or on the street. DRC, Democratic Republic of the Congo; NGO, non-governmental organisation; PWID, people who inject drugs; STI, sexually transmitted infection. https://doi.org/10.1371/journal.pmed.1002680.t003 Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 34 / 54 https://doi.org/10.1371/journal.pmed.1002680.t003 https://doi.org/10.1371/journal.pmed.1002680 but, in common with experiences in Sri Lanka [120], others encouraged them to provide offi- cers free sexual services to avoid their prosecution [132]. In India, some brothel owners paid police to avoid raids, or allowed pre-selected sex workers to be arrested [99]. Police harass- ment, raids [35,110,120], undercover operations, entrapment, and pressure to act as infor- mants [97,128] generated fear, anxiety, and stress, with media sometimes publicising sex workers’ faces during raids [120]. Conversely, where certain indoor work places were informally approved by police in a wider landscape of criminalisation, as occurred in low-barrier housing for women in Canada, the removed threat of criminal penalties fostered venue-level safety strategies, in which sex workers could refuse unprotected sex or call the police in the event of a client becoming violent (Quote 7) [113]. Similarly, in the context of decriminalisation in New Zealand, cis female sex workers working on the street reported greater police presence contributing to their protection as well as increased time for screening clients (Quotes 8 and 9) [36,94–96]. Sex workers across sectors reported being able to negotiate services more directly and refuse clients [36]. Police became more focused on sharing information with women about violent incidents or individ- uals, and when their presence was off-putting to clients, women could request that they left [96]. Sex workers working outdoors no longer needed to move to isolated areas [94], although they continued to experience verbal and physical abuse by passers-by [95]. Although sex worker organisations objected to mandatory condom use within this model, some sex workers felt that it helped them insist on condom use [36]. In contexts of regulation in Australia, Mexico, and the US, venue-level systems such as alarms, fixed prices, intercoms, and condom use [100,124], as well as being able to work in close proximity with other sex workers and third parties [35,100,101,124], improved control and sense of safety for those able to work in regulated venues. Yet, in the US, some women criticised such systems as a veiled means of surveillance and as protecting management and clients’ interests above their own safety [100]. Across these settings, those unable to conceal venue-prohibited substance use were excluded from these premises and left as the authors note with ‘no choice but to work on the streets’ [124] or in the minority of venues where man- agement overlooked these regulations [35,100,101]. In Canada, the cost of business licenses and the ineligibility of those with criminal records restricted access to and mobility between regulated venues [93,121]. In Mexico, only well-networked, resident, HIV-negative, cis female sex workers gained access to tolerance zones and regulated venues, which offered fewer physi- cal risks than unregulated indoor and outdoor settings but were often overcrowded, making income less stable [35,101]. In Australia, Guatemala, and Mexico, the ineligibility of minors to work in regulated venues meant that they had to work on the street [35,124,126]. In Australia and Sri Lanka, sex workers operating in unregulated venues had less control over negotiations with clients, and some owners encouraged women to provide sex without a condom [124,120]. Core category 2: Institutionalised violence, coercion, and extortion, and restricted access to justice. Studies showed that policing practices in contexts of criminalisation and regulation institutionalised violence against sex workers, both directly through police inflicting physical or sexual violence or demanding fines in lieu of arrest, and indirectly by restricting access to justice and thus creating an environment of impunity for perpetrators of violence [97,102,122,125,127–130]. Violence and abuses of power by police were reported across all genders and diverse politi- cal and economic contexts, including Cambodia, Canada, the Democratic Republic of the Congo, India, Kenya, Nepal, Nigeria, Pakistan, Serbia, South Africa, Sri Lanka, Thailand, Uganda, the US, and Zimbabwe [49,97,99,104,106,111,112,118,119,122,125,127,128]. This took the form of arbitrary arrest and detention, verbal harassment, intimidation, humiliating and derogatory treatment, extortion, forcible displacement, physical violence, gang rape, and Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 35 / 54 https://doi.org/10.1371/journal.pmed.1002680 other forms of sexual violence during raids and in police custody [49,97,99,103,104,106,111, 112,118,122,127,128]. In Kenya, Mexico, Nepal, Pakistan, Serbia, Sri Lanka, and the US, sex workers experienced extortion (unofficial ‘fines’, payments, or bribes) or provided sexual ser- vices enforced through physical or sexual violence or under threat of detention, arrest, transfer to rehabilitation centres, or forced registration (Quotes 10 and 11) [49,101,103,110,119, 122,128–130], with limited or no opportunity to negotiate condom use [128]. Similar extortion and/or arbitrary fines were reported in China, India, Thailand, and Turkey (Quote 12) [99,107,110,125]. In Nepal, cis female sex workers, including those hired as peer educators, reported being arrested, beaten, and robbed by police upon being found in possession of con- doms [106]. Reporting violence could result in sex workers’ being further criminalised [49,97,120– 122,127,128]. Sex workers were reluctant to report violence and theft to the police [98,125] for fear of the following: arrest for prostitution-related activities, unrelated petty offences, or non- payment of previous fines [97,98,116,120,124,131]; being accused of crimes they had not com- mitted [49,103]; harsh treatment or moral judgement [97,120]; further extortion or violence [35,101,112]; disclosure in court [97]; prohibitive costs [112]; or because no action would be taken to address the crime [97,111,112,114,116]. Long-standing discrimination, and the sense that police viewed them as criminals, made sex workers doubt the police would take com- plaints seriously [114,115,128]. When reports were submitted to police, sex workers’ accounts were dismissed as implausible, with police simultaneously blaming sex workers for the vio- lence they had experienced [49,120,125], discrediting them as victims (Quote 13) [97,103, 121,127,128], and sometimes further attacking or extorting them [49]. Cis and trans women in Canada and the US reported police questioning whether it is possible for a sex worker to be raped [97,128]. (Quote 14). Similarly, in Kenya, one cis woman reported being asked by an officer ‘how a prostitute like me could be raped as I was used to all sizes’, discouraging her from going to the police in future: ‘Never will I again go to report a case’ [127]. This produces an environment of impunity, where further violence, extortion, and theft from police and oth- ers operate unchecked [98,103,120,121,125,127], perceived to be a major contributor in nor- malising violence against sex workers [26,125]. Reluctance to report violence occurred even in contexts where the purchase but not the sale of sex was criminalised, due to fears that information about where sex work takes place could be used to target clients and harass sex workers (Quote 15) [34,114]. While some cis and trans women in Canada felt that police were now more concerned for their safety [26,114], others felt that officers continued to view them as ‘trash’, blame them for the violence they experi- enced, and deprioritise their safety [97], despite laws and police guidelines constructing them as victims [26]. In contexts of regulation, registered sex workers in Guatemala viewed their health cards (recording compliance with mandatory testing) as protective against police and immigration harassment [126,132], and registered sex workers in Mexico had better access to police protection but rarely reported violence [35]. In Senegal, registered workers still experi- enced being disbelieved when reporting physical or economic violence to police and so were reluctant to report it as a result (Quote 16) [105]. Concerns about being exposed to family and friends were paramount [35,105] and deterred some from registering [126]. Relationships with police were precarious, conditional on maintaining registered status, which can vary each month depending on compliance with mandatory screening requirements—with those whose registration has (temporarily) lapsed facing arrest, detention, and/or fines (Quote 17) [35,126]. Those who were not registered were afraid they would be sent to jail or fined for working ille- gally, or for active drug use [35], and were more heavily targeted by police for fines, arrest, detention, extortion, and sometimes sexual violence [35,101,124]. In India, marked reductions in police raids and violence were achieved through a peer-based intervention that facilitated Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 36 / 54 https://doi.org/10.1371/journal.pmed.1002680 access to justice and challenged power relations between sex workers and police, although some officers cited lengthy procedures to dissuade reporting [99]. In Canada, Mexico, Thai- land, and the US, some sex workers described certain officers’ concern for their safety and sup- port, but such concern was the exception [35,97,103,125]. Since decriminalisation in New Zealand, sex workers describe having better relationships with the police, and greater access to justice which—despite some prevailing mistrust in police —makes them feel safer and more confident with clients [36,95,96] and more deserving of respect (Quote 18) [36]. The removal of threat of arrest—which reduced police power and afforded sex workers rights—gave sex workers, and particularly young people [95], greater confidence to report violent incidents, exploitation by managers, and disputes with clients [36,96]. However, some officers treated disputes with clients as breaches of contract rather than crimes [96]. While there were still some reports of abuses of police power, there were also examples of offending officers being prosecuted as a result, helping to challenge environments of impunity [36,94,96]. Core category 3: Reproduction of multiple stigmas and inequalities. Findings show that repressive police treatment reinforced inequalities and entrenched marginalisation of sex workers, as well as creating disparities within sex-working communities, with police targeting specific settings or populations. In the context of full criminalisation in Sri Lanka, sex workers reported experiencing harsher punishment than their clients or managers: both sex workers and clients might be fined, but clients were not arrested or charged in the way that sex workers were [49], nor were managers of flats arrested during police raids [120]. Across settings, arrests, fines, extortion, and theft by police particularly targeted street-based sex workers [101,103,120,128], resulting in loss of income and increased economic vulnerabilities (Quote 19) [49,99,103,118,125,127,129,130]. Findings from Canada, Sri Lanka, and the US also show how criminalisation and police enforcement restricted freedom of movement, as sex workers were targeted arbitrarily by police during and outside of sex work hours and environments [49,97,103,120,128], and outed as sex workers by officers [97]. Studies showed how police targeting and mistreatment of sex workers, and inaccessibility to justice, reproduced inequalities and discrimination against sexual and gender minorities [26,49,116,119,127,129,130], people who use drugs [22,103,128,133], women, people of colour, and migrants [26,34,97,98,128,129,132]. In Serbia, Roma trans sex workers were treated with ‘contempt’ both by police enacting ‘extreme violence’ against them and by clients who expected cis women (Quote 20) [129]. In sub-Saharan Africa, male and trans sex workers described the ‘double stigma’ they faced, which could result in humiliation, ostracisation, evic- tion, and lack of access to micro-finance schemes, and this was worse in settings where homo- sexuality is also criminalised (Quote 21) [127]. In Sri Lanka, where both sex work and homosexuality are criminalised, trans sex workers were less likely to be charged than cis women but they experienced extensive extortion, humiliation, false accusations of crime, and verbal, physical, and sexual violence by officers targeting their gender expression (Quote 22) [49,120]. Similar experiences were reported among feminine-presenting male and trans sex workers in Pakistan and among trans women and sex workers of colour in Canada and the US [26,119,128]. In Canada, trans sex workers attributed officers’ lack of response to their reports of violence to the stigma and discrimination surrounding their gender, sex work, and drug use, reinforcing their self-blame [116]. Long-standing racial discrimination and community mistrust reinforced black and indige- nous sex workers’ doubts that the police would take their complaints of violence seriously [26,128], and drug use was used to undermine sex workers’ testimony against their attackers (Quote 23) [128]. In the US, one woman described what police said to an ex-boyfriend who had beaten her up: ‘You can’t go hitting her, even though I’d hit her for being a junkie’ [128]. Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 37 / 54 https://doi.org/10.1371/journal.pmed.1002680 In Canada, a cis female independent sex worker described a police officer calling her ‘just a fat. . .native whore’ [97], while some white male independent sex workers attributed their lack of police attention to their race and social and economic privilege [102]. In criminalised and regulated settings, the precarious legal status of undocumented or unregistered migrant sex workers was used by clients [127] and venue owners [132] to refuse payment, and by landlords to charge inflated rents for substandard rooms [107]. Migrant sex workers did not report violence and other crimes to the police due to fear of deportation [35,131,132] or language barriers [98]. In Guatemala, police officers sometimes rounded up migrant sex workers whether or not they were registered [126], and in Turkey, police targeted ‘foreign-looking’ women presumed to be migrant sex workers [107]. In Sweden, immigration legislation and anti-trafficking policies have been used to deport migrant sex workers, despite their characterisation in national prostitution law as victims of violence, as a way of reducing sex work [34]. Core category 4: Restricted access to health and social care and support. Research dem- onstrates how criminalisation and police enforcement restrict sex workers’ access to health and social care. In Cambodia and various sub-Saharan African countries, crackdowns on brothels have reduced access to health services by disrupting peer networks and displacing sex workers from usual places of work, making it difficult for outreach services to find people, and hindering collective organisation (Quote 24) [118,127]. In China, sex workers were reluctant to accept condoms from health services after police crackdowns, for fear of their use as evi- dence [110]. In Sweden, the mandate to reduce sex work acted as a barrier to services, as sex workers’ access became conditional on leaving the sex trade and conforming to a victim dis- course, and health services no longer distributed condoms through outreach [34]. Based on ethnographic observations, authors noted multiple difficulties experienced by sex workers as a result of laws against renting property used for sex work, including problems with eviction as well as with immigration, child custody, and tax authorities [34]. In Canada, some sex workers had received referrals from supportive police to health, counselling, and legal aid services [97], but indoor venue managers remained reluctant to allow outreach visits for fear of prosecution, restricting access to sexual and broader healthcare—particularly disadvantaging migrant sex workers who relied on outreach [93]. Trans sex workers in Canada [116] and sex workers of all genders in South Australia [98] were fearful of accessing clinics [116], sex-worker-led outreach services, and peer information and resources [98], for fear of being reported to the police. Studies showed how registration and mandatory testing necessitated more frequent contact with healthcare systems [100,108,115,132] and were viewed positively by authors in Nevada, US, as a way of maintaining a low level of STIs [100] and by some sex workers as a form of self-responsibility for health [108,126]. However, in Guatemala the decision to comply with testing requirements was mostly motivated by fear of police harassment and detention rather than health considerations [126,132]. In Turkey, unregistered migrant sex workers were forc- ibly tested upon arrest [107], and in Australia, some sex workers experienced judgement and were refused testing by health professionals [108]. Mandatory testing of sex workers is consid- ered a rights violation by the UN Refugee Agency and the Joint United Nations Programme on HIV/AIDS that can create barriers to sex workers accessing voluntary services and can facilitate discrimination against sex workers living with HIV. In Nevada, sex workers who test HIV positive can face up to 10 years in prison if they are found selling sex in a licensed or an unlicensed environment [100]. Discrimination against sex workers in general was often rein- forced, and mandatory registration was not only time-consuming but could lead to public dis- closure of sex work, adversely affecting individuals’ credit rating and ability to obtain a loan (Quotes 25–28) [108,115,127]. Regulation systems also restricted migrants’ access to sexual health services [35], and those with undocumented status in Turkey lacked broader access to Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 38 / 54 https://doi.org/10.1371/journal.pmed.1002680 healthcare and banking services, leaving them vulnerable to theft [107]. In Canada, sex work- ers’ fear of becoming known to the authorities left them dependent on cash and unable to access loans [107,121]. Box 1. Quotes Core category 1: Disrupted work spaces and safety strategies Quote 1: ‘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 danger- ous. I don’t think it was the original intention, but that’s what it does.’—cis woman, sec- tor and age unspecified, Canada [121] Quote 2: ‘Twenty seconds, one minute, two minutes, you have to decide if you should go into this person’s car. . .now I guess if I’m standing there, and the guy, he will be really scared to pick me up, and he will wave with his hand “Come here, we can go here round the corner, and make up the arrangement”, and that would be much more dangerous.’— cis woman, internet escort/street, age unspecified, Canada [34] Quote 3: ‘While they’re going around chasing johns away from pulling up beside you, I have to stay out for longer.. . .Whereas if we weren’t harassed we would be able to be more choosy as to where we get in, who we get in with you know what I mean? Because of being so cold and being harassed I got into a car where I normally wouldn’t have. The guy didn’t look at my face right away. And I just hopped in cause I was cold and tired of standing out there. And you know, he put something to my throat. And I had to do it for nothing. Whereas I woulda made sure he looked at me, if I hadn’t been waiting out there so long.’—cis woman, street, age unspecified, Canada [114] Quote 4a: ‘Sometimes the guy will drive up and just sort of wave or point to go down the alley or something like that somewhere else where he can pick me up. [How does that affect your safety?] You never know who it is, right? And you can’t really see his face, can’t really see anything they could have a gun in their hand or. You know what I mean they could be a little drunk or something if you can’t really see them very clearly, you know. And you don’t you can’t say hi or whatever before you get in. You have to just hurry up before the cops come.’—cis woman, street, age unspecified, Canada [114] Quote 4b: ‘Clients are worried about police. To avoid police they wanna move to a different area. I don’t want to go out of my zone right.. . .Once you get out there, like you know their turf so it’s harder for me cause it’s their comfort zone so they act differently, you know what I mean. Yeah it never ends up good’—cis woman, street, age unspecified, Canada [114] Quote 5: ‘The ideal situation is where you. . .have a separate premises where you can work from, and share those premises. . .Because then you’ve got companionship, added security, there’s someone to interact with. Because of the legal situation you have to be very, very careful. Because obviously it’s running a brothel, which has. . .really dangerous consequences these days.’—cis man, independent, age unspecified, UK [123] Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 39 / 54 https://doi.org/10.1371/journal.pmed.1002680 Quote 6a: ‘In the past, we just stay in the brothel and no one dared to hurt us or beat us because we are there in the brothel. But now [since police crackdowns] we cannot know where they take us to. Such as taking us to Prek Ho [a village 15 km from Phnom Penh] and hurt us. We don’t know in advance. There is no one to control us. So it is not safe for us.’—cis woman, formerly brothel-based, age 26 years, Cambodia [118] Quote 6b: ‘Now some clients may force us not to use condoms but when we lived in the brothel we had more rights than clients and they dared not to force us because they come into our house.’—cis woman, formerly brothel-based, age 22 years, Cambodia [118] Quote 7: ‘One of the staff caught one [a violent client]. He was a visitor in the house, and he came in as a date, and they called the police, and he got arrested.’—cis woman, indoor, age unspecified, Canada [113] Quote 8: ‘And the police weren’t around as much (before decriminalization). But when it got legalised the police were everywhere. We always have police coming up and down the street every night, and we’d even have them coming over to make sure that we were all right and making sure our minders, that we’ve got minders and that they were taking registration plates and the identity of the clients. So it was, it changed the whole street, it’s changed everything.’—cis woman, street, age unspecified, New Zealand [36] Quote 9: ‘You stand outside the car and talk. Don’t get in the car and talk—it’s best to just get them to wind the window down, stand there, talk to them and judge them. Yeah.’—cis woman, street, age unspecified, New Zealand [94] Core category 2: Institutionalised violence, coercion, and extortion, and restricted access to justice Quote 10: ‘There was this time when I was arrested by six policemen. They afterwards demanded sex from me. One of them threatened to stab me if I refused. I ended up hav- ing sex with all of them and the experience was so painful.’—cis man, sector unspecified, age 26 years, Kenya [127] Quote 11: ‘It’s really pathetic taking money from us. I don’t know how they don’t under- stand I struggled for that. I sold my body. I worked. The man, for instance, pardon me, fucked me and everything, for the money. And they take the money. Why? I don’t know, but so they say it goes into some fund, what do I know?’—cis woman, street, age not specified, Serbia [129] Quote 12: ‘Does the law limit how much they [police] charge [when fining sex workers]? Today, 500, tomorrow 300. Why the law does not limit. . .the charges for this amount? For gambling, 1000 charged, prostitution 500, isn’t there a limit? We don’t understand. I feel like the charges just depend on their [police] mood.’—cis woman, focus group, sec- tor and age not specified, Thailand [125] Quote 13: [In a case where a participant reported being attacked by a client and the case going to court.] ‘He ended up getting off even though I had photos of the bruises. This is likely related to the institutional attitude that women who sell sex deserve what they get from taking on a dangerous occupation—it’s such bullshit but so common! Also, I feared prosecution myself as a prostitute so I was unable to be completely truthful in court and my abuser was let off—even with the evidence’—cis woman, independent off street, age not specified, Canada [121] Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 40 / 54 https://doi.org/10.1371/journal.pmed.1002680 Quote 14: ‘The police don’t look at us as victims when we’re raped and when we’re beaten and stuff like that. If we get into a physical altercation and we have to fight for our lives, we’re most likely to be jailed because of it.’—cis woman, sector not specified, age 40 years, US [128] Quote 15: ‘They come to my door and, you know, ask for my ID and so forth so it’s like harassment. . .The third time it’s like, “We know what you’re doing, I mean, what you’re about. We’re going to go after your clients”. . .I make a living out of this, so I was really paranoid for a very long time after.’—cis woman, internet escort, age not specified, Swe- den [34] Quote 16: ‘One night a client went off with a girl, and after their encounter he beat her. The next day she recognised him in the bar and told the bar owner who told her to go to the police. When she got to the police station the officers didn’t believe her—they said she didn’t have any proof. The police don’t give us any help at all.’—cis women, working in a bar with registration, age not specified, Senegal [105] Quote 17: ‘Once, I forgot to return [to the city clinic] for a health stamp. The police threatened to take me and nine other girls to jail, but they let us go with a warning and a 2,000 pesos fine [$220].’—cis woman, sector not specified, age 19 years, Mexico [35] Quote 18: ‘Well it definitely makes me feel like, if anything were to go wrong, then it’s much more easier for me to get my voice heard. And I also, I also feel like it’s some kind of hope that there’s slowly going to be more tolerance perhaps of you know, what it is to be a sex worker. And it affects my work, I think. . .when I’m in a room with a client. . .I feel like I am deserving of more respect because I’m not doing something that’s illegal. So I guess it gives me a lot more confidence with a client because, you know, I’m doing something that’s legal, and there’s no way that they can, you know, dispute that. And you know, I feel like if I’m in a room with a client, then it’s safer, because, you know, maybe if it wasn’t legal, then, you know, he could use that against me or threaten me with something, or you know. But now that it’s legal, they can’t do that.’—cis woman, sector and age not specified, New Zealand [36] Core category 3: Reproduction of multiple stigmas and inequalities Quote 19: ‘Now if I get caught to police people, they check pockets and all and take everything.. . .the police people will snatch it [money] away. . .Even if we find two hun- dred [rupees] a police person will come [and take it].’—trans woman (nachichi), street, age unspecified, Sri Lanka [49] Quote 20: ‘They [police] started going wild, only on us transvestites. They let the girls go. They just pick us up, and go to the woods, and go wild on us. . .First, they beat us in the woods, and then they take us to the station. And then they tell us at the station “Hey, freshen up,” and they beat us up in the bathroom’—transvestite [author’s term], street, age unspecified, Serbia [129] Quote 21: ‘Sometimes a man will take you and after fucking, he says, “You are gay, where can you report me? I’m not paying you and you can do nothing about it.”‘—cis man, focus group, sector and age unspecified, Uganda [127] Quote 22: [After reporting being jailed on charges of prostitution and describing an inci- dent with police involving forced gender behaviour] ‘I’m very scared of policemen of Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 41 / 54 https://doi.org/10.1371/journal.pmed.1002680 Discussion We estimate that, collectively, lawful or unlawful repressive policing practices linked to sex work criminalisation (partial or full) are associated with increased risk of infection with HIV or STIs, sexual or physical violence from clients or intimate partners, and condomless sex. The qualitative synthesis clearly shows pathways through which these policing practices and health risks are associated: enacted or feared police enforcement—targeting sex workers, clients, or third parties organising sex work—displaces sex workers into isolated and dangerous work locations and disrupts risk reduction strategies, such as screening and negotiating with clients, carrying condoms, and working with others. Specific policing practices, including confiscation of condoms or needles/syringes, are associated with increased odds of HIV, STIs, and violence course.. . .They straight away tell.. . .“Go sing a song! sweep!” Talk to us like dogs.’— trans woman, street, age unspecified, Sri Lanka [49] Quote 23: ‘Because it wasn’t a trial of rape, it was a trial of me being a heroin addict, me being on methadone. It got thrown out of court. . ..’—cis woman, street, age unspecified, Canada [22] Core category 4: Restricted access to health and social care and support Quote 24: ‘Since the new law was passed, fewer women access health care and prevention services because we live at different places nowadays and NGOs could not find us. In the past, women live in one place at the brothel. We also want to contact NGOs but we don’t know the location of the NGOs. . .So we could not access to prevention services. . .Since the brothel was closed I have never contacted it again.’—cis woman, brothel, age 22 years, Cambodia [118] Quote 25: ‘Because the policemen crack down often we cannot earn money. We are sleepless, so we sleep at day time, so I am lazy to go to check my health. I have no feeling to go.’—cis woman, brothel, age 22 years, Cambodia [118] Quote 26: ‘I think every month is stupid. It has to be every three months at least. Because it’s a pain for owners, it’s a pain for girls, for everyone, because like you can’t go to your family doctor and say, “Listen I need a certificate”. You have to go to a sexual health clinic and wait all day to see a doctor.’—cis woman, brothel and escort, age unspecified, Australia [108] Quote 27: ‘[For] any insurance one of the questions is, “Have you been a prostitute?” Whatever, now if they pulled your health records and they saw how many tests you’d had, you can’t lie about that one and I think it should be totally illegal [insurance compa- nies asking about sex work]. And I would like to see them do a bit of a study on girls in the sex industry who have worked, that aren’t on drugs and how many diseases they actually have, to see if this kind of discrimination is warranted, because it’s not.’—cis woman, sector and age unspecified, US [108] Quote 28: ‘I worked in a legal prostitution setting in Nevada. I did that for a couple of weeks to see what it was like. The amount of controls and the lack of freedom was hor- rendous. You know, I don’t want someone else telling me how to work. And I don’t think it is necessary really. Yeah, I think decriminalization gives us the most freedom.’— cis woman, independent in-call and out-call, age 39 years, US [115] Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 42 / 54 https://doi.org/10.1371/journal.pmed.1002680 by a range of actors. Repressive police practices frequently constitute basic violations of human rights, including unlawful arrest and detention, extortion, physical and sexual violence by law enforcement, lack of recourse to justice, and forced HIV testing—violations inextricably linked to increased unprotected sex, transmission of HIV and STIs, increased violence from all actors, and poorer access to health services [3,29,134]. The qualitative synthesis shows how violence and stigma against sex workers are institutionalised, legitimised, and rendered invisi- ble [26,35] in contexts of any criminalisation and regulation [26,35], as sex workers across set- tings consistently report being further criminalised, blamed, or ignored when they report crimes against them. This structural, symbolic, and everyday violence fosters climates of impu- nity and under-reporting, and failure to recognise sex workers as citizens deserving protection, care, and support [26]. Targeting and exclusion of the most marginalised sex workers rein- forces and obscures the injustices they face. Our findings build on previous reviews documenting the extent to which and how social and structural factors influence sex workers’ safety and vulnerability to HIV. They do so by showing how these factors interplay with criminalisation to further marginalise sex workers and deprive them of civil, labour, and social rights [134–137]. Fear of prosecution and moral judgement, due to laws against homosexuality and transgenderism [138] and drug use [135], and, in the case of migrant workers [139], fear of deportation, further reduce willingness to report violence and exploitation to the police. Other evidence has shown how evictions based on landlords’ fears of brothel-keeping charges increase vulnerability to homelessness for sex workers and their families, while arrest and criminal records or simply being identified as a sex worker can lead to sex workers’ children being placed in institutional care [135,140]. Despite including search terms relating to broader health outcomes, the majority of epide- miological literature focused on sexual health outcomes and, in more recent evidence, vio- lence. We found few studies that focused on emotional health, but these show detrimental associations with repressive policing and criminalisation. Qualitative and quantitative studies demonstrate that police enforcement and its threat is a major source of anxiety [103,141], whereas working in indoor, decriminalised environments is associated with improved mental health outcomes [32,142]. A recent critical literature review demonstrates that criminalisation, stigma, poor working conditions, isolation from peer and social networks, and financial inse- curity have negative repercussions for sex workers’ mental health [13]. Only 1 quantitative study reported on the associations between policing and violence from intimate or other part- ners, and further research is needed to understand the mechanisms of this relationship [58]. It is clear that criminalisation and stigma interact to reproduce sex workers’ exposure to physical and sexual violence, and limit possibilities to resist or challenge it, and interventions are urgently needed to address violence against sex workers from all perpetrators. Successful sex- worker-led approaches to improving access to justice and challenging institutional stigma in South India offer important examples of what can be achieved with sustained funding and sup- port [99]. Findings clearly show that criminally enforced regulatory models create major disparities within sex worker communities, possibly enabling access to safer conditions for some but excluding the large majority who remain under a system of criminalisation, including trans women, cis men, people who use drugs, migrant populations, and often sex workers operating in outdoor environments, who are at increased risk of HIV in many settings [81,90,126]. In contexts of mandatory HIV testing following arrest, fear of enforcement can hinder voluntary uptake of HIV testing and interventions [71,80], showing how this punitive approach to public health ultimately reduces access to health services. More recent research from Senegal has shown that while registration was associated with better physical health, the stigma attached to being registered has a detrimental effect on well-being; only a minority of sex workers are Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 43 / 54 https://doi.org/10.1371/journal.pmed.1002680 registered, and those who test HIV positive are excluded [143]. As the qualitative synthesis demonstrates, in New Zealand, following decriminalisation, sex workers reported being better able to refuse clients and insist on condom use, amid improved relationships with police and managers [36,144,145]. Other research in this setting indicates that decriminalisation has the potential not only to reduce discrimination, denials of justice, denigration, and verbal abuse but also to improve sex workers’ emotional well-being [31]. This concords with existing modelling data that suggest a positive effect of decriminalisation on incidence of HIV [2]. We were unable to examine the effects of different legislative models in the quantitative synthesis due to limited data, particularly for the models of decriminalisation and the crimina- lisation of the purchase of sex. Evidence included in our qualitative synthesis clearly shows that criminalisation of clients does not facilitate access to services, nor minimise violence. This is supported by the epidemiological evidence from Vancouver that showed that sex workers who were stopped, searched, or arrested were at increased risk of client violence despite the introduction of more severe laws against the purchase of sex introduced in 2014 (alongside fewer sanctions for sex workers working together and modelled on the Swedish law) [57]. In addition, the practice of rushing negotiations due to police presence increased and was associ- ated with increased client-perpetrated violence [92]. Findings from our qualitative synthesis suggest that enforcement strategies that seek to reduce the numbers of sex workers [118] or cli- ents [114] are unlikely to achieve these effects, since the economic needs of sex workers remain unchanged, resulting in sex workers having to work longer hours, accept greater risks, and deprioritise health. There is no reliable evidence from Sweden that the numbers of sex workers have decreased since the law changed in 1999 [34]. Limitations There are a number of limitations to this review. Findings from our pooled meta-analyses examining condom use and violence were limited by high heterogeneity, although effect esti- mates remained consistent across sensitivity analyses, suggesting we can be confident in their robustness. By limiting the search to literature written in English, Russian, and Spanish, we may have missed key studies. 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. Similarly, few qualitative studies explored the emotional health effects of crimina- lisation and enforcement, and its effects on access to health and broader services received less attention relative to safety and health risks, within the rich body of evidence reviewed. Method- ologically, some studies did not provide sufficient detail on sampling and analysis methods, and few included reflexive discussions on the position of the researcher. Although a growing num- ber involve sex workers as researchers or advisors, few included discussion of the challenges and benefits of participatory approaches. We found few eligible studies that included trans female or cis male sex workers, who experience particular inequalities in relation to HIV, access to services, and—as the qualitative synthesis shows—police targeting and violence, limiting our ability to generalise findings to these populations. It is also possible that some studies may not have differentiated between trans women and cis men [146], or between cis and trans partici- pants within samples of female and male sex workers, and few disaggregated experiences or out- comes by gender. This is an important area of future research given the specific vulnerabilities experienced by these populations, in contexts where gender and sexual minorities are crimina- lised, inadequately protected against hate crimes, and, in the case of trans people, not legally rec- ognised. There is particular need for research with trans women, who experience intense violence, discrimination, and exclusion from education and employment, and whose health needs have been obscured by their conflation with ‘men who have sex with men’ [146]. Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 44 / 54 https://doi.org/10.1371/journal.pmed.1002680 Our review focuses on the implementation of enforcement practices linked to 5 broad legis- lative models. While it is clear that sex work laws and enforcement practices are inextricably integrated and it is key to link practice to legal frameworks to inform policy-making and advo- cacy, our findings reinforce previous evidence [37,38] that shows wide variation in how laws are enforced, which vary with sex work setting [126], visibility of sex work, sex workers’ and managers’ relationships with individual officers [99,101], and political and media attention [110,125], or arbitrarily by city [121]. We report on recent and past history of arrest or prison based on the information available to us, but few studies reported whether the arrest was related to sex work, was related to another offence, or had to do with social, gender, or racial profiling. Assessing the extent to which the enforcement practice was lawful or unlawful is beyond the scope of this review, but in some cases unlawful activities are clearly evidenced (e.g., police violence) while in others they are less visible or evidenced. This limits our ability to assess the specific contribution of sex work penalties to the health and safety of sex workers, relative to the use of other penalties and abuses of police powers against sex workers in con- texts of criminalisation. Lack of clarity on the lawfulness of police enforcement practices also reflects the difficulties in measuring stigma and its interaction with criminalisation, and the need for mixed-methods approaches to unpack these complexities in context. We found few data on the interplay between criminalisation, collective organisation, and health outcomes. Evidence from India has shown how tackling social injustice and mistreatment by the police as part of a sex-worker-led HIV prevention intervention has resulted in fewer arrests, more explanation of reasons for arrest, and fairer treatment by the police, as well as decreased violence against sex workers [84,99]. However, most evaluations of community-led health interventions have been limited to HIV prevention and have been implemented in India, Dominican Republic, and Brazil [147,148]. Although there are numerous examples of active sex worker organisations advocating for sex worker rights and evidence-based policy interna- tionally, as well as developing guidelines for rights-based HIV programming with, for, and by sex workers [149], the voices of sex workers continue to be dismissed and silenced in policy debates in many settings as well as in the design and evaluation of public health interventions. Conclusion The public health evidence clearly shows the harms associated with all forms of sex work crimi- nalisation, including regulatory systems, which effectively leave the most marginalised, and typi- cally the majority of, sex workers outside of the law. These legislative models deprioritise sex workers’ safety, health, and rights and hinder access to due process of law. The evidence available suggests that decriminalisation can improve relationships between sex workers and the police, increasing ability to report incidences of violence and facilitate access to services [36,95,96]. Con- sidering these findings within a human rights framework, they highlight the urgency of reform- ing policies and laws shown to increase health harms and act as barriers to the realisation of health, removing laws and enforcement against sex workers and clients, and building in health and safety protections [134]. It is clear that while legislative change is key, it is not enough on its own. Law reform needs to be accompanied by policies and political commitment to reducing structural inequalities, stigma, and exclusion—including introducing anti-discrimination and hate crime laws that protect sex workers and sexual, gender, racial, and ethnic minorities. Mixed-methods, interdisciplinary, and participatory research is needed to document the con- text-specific ways in which criminalisation or decriminalisation interacts with other structural factors and policies related to stigma, poverty, migration, housing, and sex worker collective organising, to inform locally relevant interventions alongside legal reform. This research must go alongside efforts to examine concerns surrounding decriminalisation of sex work within Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 45 / 54 https://doi.org/10.1371/journal.pmed.1002680 institutions and communities, which influence policy and practice, and sex workers must be involved in decision-making over any such research and reforms [121,150]. Opponents of decri- minalisation of sex work often voice concerns that decriminalisation normalises violence and gender inequalities, but what is clear from our review is that criminalisation does just this by restricting sex workers’ access to justice and reinforcing the marginalisation of already-margina- lised women and sexual and gender minorities. The recognition of sex work as an occupation is an important step towards conferring social, labour, and civil rights on all sex workers, and this must be accompanied by concerted efforts to challenge and redress cultures of discrimination and violence against people who sell sex. While such reforms and related institutional shifts are likely to be achieved only in the long term, immediate interventions are needed to support sex workers, including the funding and scale-up of specialist and sex-worker-led services that can address the multiple and linked health and social care needs that sex workers may face. Supporting information S1 Moose Checklist. (DOC) S1 Fig. Sensitivity analysis of unadjusted and adjusted estimates of HIV/STI stratified by police exposure. (TIF) S2 Fig. Sensitivity analysis of unadjusted and adjusted estimates of sexual/physical violence stratified by police exposure. (TIF) S3 Fig. Sensitivity analysis of unadjusted and adjusted estimates of condomless sex strati- fied by police exposure. (TIF) S4 Fig. Sensitivity analysis of outcome misclassification. (TIF) S1 Table. Quality assessment of quantitative studies. (XLSX) S2 Table. Data used in R for meta-analysis. (XLSX) S1 Text. Systematic review protocol. (DOC) S2 Text. Summary of CERQual assessment. (DOCX) S3 Text. Category themes and sub-themes. (DOCX) S4 Text. All references reviewed as part of qualitative synthesis. (DOCX) Author Contributions Conceptualization: Lucy Platt, Pippa Grenfell, Rebecca Meiksin. Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 46 / 54 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s001 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s002 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s003 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s004 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s005 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s006 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s007 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s008 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s009 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s010 http://journals.plos.org/plosmedicine/article/asset?unique&id=info:doi/10.1371/journal.pmed.1002680.s011 https://doi.org/10.1371/journal.pmed.1002680 Data curation: Lucy Platt, Pippa Grenfell, Rebecca Meiksin, Jocelyn Elmes. 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