Parts 7 and 8 have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted.
Parts 9 and 10 have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted.
APA format
1) Minimum 18 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
Due 20 hours: 4 pages
Due 40 hours: 8 pages
Due 90 hours: 6 pages
Part 1: minimum 2 pages WR (Due 20 hours)
Part 2: minimum 2 pages WR (Due 20 hours)
Part 3: minimum 3 pages WR (Due 90 hours)
Part 4: minimum 3 pages WR (Due 90 hours)
Part 5: minimum 1 page (Due 40 hours)
Part 6: minimum 1 page (Due 40 hours)
Part 7: minimum 2 pages (Due 40 hours)
Part 8: minimum 2 pages (Due 40 hours)
Part 9: minimum 1 page (Due 40 hours)
Part 10: minimum 1 page (Due 40 hours)
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)
Parts 3 and 4: Minimum 5 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
__________________________________________________________________________________
Part 1: Writing and rhetoric
Subject: research topic statement
Topic: Deaths caused by school shootings clearly show the need to develop programs to improve students’ mental health.
Research question 1: It is possible that implementing a mental health program for students ages 11-17 in Florida high schools could reduce the incidence of shootings in schools
Research question 2: Is it possible that implementing a mental health program for students ages 11-17 in high schools in Florida could educate students about the possible risk of shootings?
1. Topic (Three paragraphs)
a. Explain your topic in the class been so far? (One paragraph)
a. What are the most heavily-debated parts of that topic (One paragraph)
b. Why do the answers to that debate matter? (One paragraph)
2. Based on the research you’ve done so far (Two paragraphs)
a. What do you know about possible answers to your question (One paragraph)
b. What do you need to look into before you can answer your research question? (One paragraph)
3. In a paragraph, list at least 5 questions you have about your topic that a source could answer for you. These questions should be things you feel you need to answer before you can answer the research questions (One paragraph)
Part 2: Writing and rhetoric
Subject: Research topic statement
Topic: Recognizing sex work would allow women in this industry to unionize and access benefits that workers in other industries have.
Research question 1: Could legally recognizing female sex work in Florida reduce the incidence of sexual diseases in this population due to free access to the health system?
Research question 2: Could legally recognizing female sex work in Florida increase the sexual health of this population due to free access to the health system?
1. Topic (Three paragraphs)
a. Explain your topic in the class been so far? (One paragraph)
a. What are the most heavily-debated parts of that topic (One paragraph)
b. Why do the answers to that debate matter? (One paragraph)
2. Based on the research you’ve done so far (Two paragraphs)
a. What do you know about possible answers to your question (One paragraph)
b. What do you need to look into before you can answer your research question? (One paragraph)
3. In a paragraph, list at least 5 questions you have about your topic that a source could answer for you. These questions should be things you feel you need to answer before you can answer the research questions (One paragraph)
Part 3: Writing and rhetoric
Four paragraphs per page
Subject: Finding and Understanding Your Sources
Purpose: Persuade your instructor and classmates that you are exploring effectively, demonstrating intellectual curiosity, reading rhetorically and with an open mind.
Audience: Your instructor and classmates
Genre: Blog
Topic: Deaths caused by school shootings clearly show the need to develop programs to improve students’ mental health.
Research question 1: It is possible that implementing a mental health program for students ages 11-17 in Florida high schools could reduce the incidence of shootings in schools
Research question 2: Is it possible that implementing a mental health program for students ages 11-17 in high schools in Florida could educate students about the possible risk of shootings?
1. Rhetorical summary Sources 1 (Check file 1) (One paragraph)
a. Introduce the source concisely
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose
2. Rhetorical summary Sources 2 (Check file 2) (One paragraph)
a. Introduce the source concisely
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose
3. Include a brief summary for each source that highlights the most important things you learned about your topic from that source. (One paragraph)
a. Source 1
b. Source 2
4. Discuss how source 1 answers your questions and/or enhances your understanding in some way. (Three paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f)
a. What was the question (or questions) that you set out to answer
b. How does this source answer those for you?
c. Justify why this was a useful source for answering your research question.
d. What aspect(s) of the problem/issue/topic does this source seem to focus on most?
e. What kinds of information does this source not discuss?
f. What new, surprising, or unexpected information came up in this source?
5. Discuss how source 2 answers your questions and/or enhances your understanding in some way.(Three paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f)
a. What was the question (or questions) that you set out to answer
b. How does this source answer those for you?
c. Justify why this was a useful source for answering your research question.
d. What aspect(s) of the problem/issue/topic does this source seem to focus on most?
e. What kinds of information does this source not discuss?
f. What new, surprising, or unexpected information came up in this source?
6. Summary of what you feel you understand about your topic (One paragraph)
a. What you are confused about
c. What questions you still have. You should also discuss:
7. Reflection (Two paragraphs: One paragraph for a and b; One paragraph for c and d)
a. What questions do you have now that you did not have before?
b. What might you want to research next?
c. What do you understand (overall) about your research question and its potential answers?
d. What aspect of the topic are you most interested in?
Part 4: Writing and rhetoric
Four paragraphs per page
Subject: Finding and Understanding Your Sources
Purpose: Persuade your instructor and classmates that you are exploring effectively, demonstrating intellectual curiosity, reading rhetorically and with an open mind.
Audience: Your instructor and classmates
Genre: Blog
Topic: Recognizing sex work would allow women in this industry to unionize and access benefits that workers in other industries have.
Research question 1: Could legally recognizing female sex work in Florida reduce the incidence of sexual diseases in this population due to free access to the health system?
Research question 2: Could legally recognizing female sex work in Florida increase the sexual health of this population due to free access to the health system?
1. Rhetorical summary Sources 1 (Check file 1) (One paragraph)
a. Introduce the source concisely
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose
2. Rhetorical summary Sources 2 (Check file 2) (One paragraph)
a. Introduce the source concisely
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose
3. Include a brief summary for each source that highlights the most important things you learned about your topic from that source. (One paragraph)
a. Source 1
b. Source 2
4. Discuss how source 1 answers your questions and/or enhances your understanding in some way. (Three paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f)
a. What was the question (or questions) that you set out to answer
b. How does this source answer those for you?
c. Justify why this was a useful source for answering your research question.
d. What aspect(s) of the problem/issue/topic does this source seem to focus on most?
e. What kinds of information does this source not discuss?
f. What new, surprising, or unexpected information came up in this source?
5. Discuss how source 2 answers your questions and/or enhances your understanding in some way.(Three paragraphs: One paragraph for a and b; One paragraph for c and d; One paragraph for e and f)
a. What was the question (or questions) that you set out to answer
b. How does this source answer those for you?
c. Justify why this was a useful source for answering your research question.
d. What aspect(s) of the problem/issue/topic does this source seem to focus on most?
e. What kinds of information does this source not discuss?
f. What new, surprising, or unexpected information came up in this source?
6. Summary of what you feel you understand about your topic (One paragraph)
a. What you are confused about
c. What questions you still have. You should also discuss:
7. Reflection (Two paragraphs: One paragraph for a and b; One paragraph for c and d)
a. What questions do you have now that you did not have before?
b. What might you want to research next?
c. What do you understand (overall) about your research question and its potential answers?
d. What aspect of the topic are you most interested in?
Part 5: Conditions and diagnosis in recreation
Topic: Down syndrome and recreational therapy
According to file 1 (see file attached)
1. Write an abstract (Three paragraphs)
Part 6: Conditions and diagnosis in recreation
Topic: Down syndrome and recreational therapy
According to file 2 (see file attached)
1. Write an abstract (Three paragraphs)
Parts 7 and 8 have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted.
Part 7: Recreational Therapy
According to the link
https://fiu.instructure.com/media_objects_iframe/m-3oQ1pdESQkptAfkeprVVUyjUJDDbQj4G?type=video?type=video
1. Guest speaker’s background
a. Description of the agency they work at
2. What populations are served
a. Types of activities that are offered
b. General job responsibilities
3. Summary of what was mentioned about the APIED process (Assessment, Planning, Implementation, Evaluation and Documentation)
a. How this is implemented at their workplace
4. Explain recreational therapy services offered at these different locations.
a. CTRS at Catawba Hospital
b. CTRS at LAC + USC Medical Center
c. CTRS at West Texas VA Medical Center
5. Reflection
a.Takeaways and interesting things you learned
b. Discussion of personal fit for this setting based on personal attributes, interests, skills and career goals
Part 8: Recreational Therapy
According to the link
https://fiu.instructure.com/media_objects_iframe/m-3oQ1pdESQkptAfkeprVVUyjUJDDbQj4G?type=video?type=video
1. Guest speaker’s background
a. Description of the agency they work at
2. What populations are served
a. Types of activities that are offered
b. General job responsibilities
3. Summary of what was mentioned about the APIED process (Assessment, Planning, Implementation, Evaluation and Documentation)
a. How this is implemented at their workplace
4. Explain recreational therapy services offered at these different locations.
a. CTRS at Children’s Healthcare of Atlanta Hospital
b. CTRS at LAC + USC Medical Center
c. CTRS at Palace Gardens Assisted Living Facility
5. Reflection
a.Takeaways and interesting things you learned
b. Discussion of personal fit for this setting based on personal attributes, interests, skills and career goals
Parts 9 and 10 have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted.
Part 9: Inclusive recreation
Topic: Leisure Services with Aging Families
Read the file attached part 9 and 10
1. What do you think was Morrie’s main point?
2. How do you feel about how Morrie characterizes young adults?
3. What stereotypes do you hold about older adults?
Check:
https://www.youtube.com/watch?v=WTbtJgGPYIo
4. How does Sterling Estates promote healthy aging and consider inclusion in older adults?
5. How might you, as a future leisure service provider, promote continuity in the lives of older adults?
Part 10: Inclusive recreation
Topic: Leisure Services with Aging Families
Read the file attached part 9 and 10
1. What do you think was Morrie’s main point?
2. How do you feel about how Morrie characterizes young adults?
3. What stereotypes do you hold about older adults?
Check:
4. How does Sterling Estates promote healthy aging and consider inclusion in older adults?
5. How might you, as a future leisure service provider, promote continuity in the lives of older adults?
Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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as:
Sex Relation Ther. 2019 ; 34(3): 355–371. doi:10.1080/14681994.2019.1574970.
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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].
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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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
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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)
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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)
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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
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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
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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
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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)
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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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https://doi.org/10.1371/journal.pmed.1002680
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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https://doi.org/10.1371/journal.pmed.1002680
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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https://doi.org/10.1371/journal.pmed.1002680
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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Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global under- standings of HIV prevalence. Glob Public Health. 2016; 11(7–8):849–65. https://doi.org/10.1080/ 17441692.2016.1181193 PMID: 27173599 147. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and con- siderations for implementation and scale-up. Lancet. 2015; 385(9963):172–85. https://doi.org/10. 1016/S0140-6736(14)60973-9 PMID: 25059938 148. Cornish F, Campbell C. The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa. Am J Community Psychol. 2009; 44(1–2):123–35. https://doi.org/10.1007/s10464-009-9254-8 PMID: 19521765 149. World Health Organization. Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries. Recommendations for a public health approach. Geneva: World Health Organization; 2012. 150. Agata D, Stevenson L. Nothing about us without us! Amsterdam: International Committee on the Rights of Sex Workers in Europe; 2015. Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 54 / 54 https://doi.org/10.1080/17441692.2016.1181193 https://doi.org/10.1080/17441692.2016.1181193 http://www.ncbi.nlm.nih.gov/pubmed/27173599 https://doi.org/10.1016/S0140-6736(14)60973-9 https://doi.org/10.1016/S0140-6736(14)60973-9 http://www.ncbi.nlm.nih.gov/pubmed/25059938 https://doi.org/10.1007/s10464-009-9254-8 http://www.ncbi.nlm.nih.gov/pubmed/19521765 https://doi.org/10.1371/journal.pmed.1002680
Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680.t001
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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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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https://doi.org/10.1371/journal.pmed.1002680
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
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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)
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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)
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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)
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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
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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
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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)
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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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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.t002
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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https://doi.org/10.1371/journal.pmed.1002680.g002
https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g003
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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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
Public Access Author m
anuscript
Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.
Published in final edited form
as:
Sex Relation Ther. 2019 ; 34(3): 355–371. doi:10.1080/14681994.2019.1574970.
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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Weitzer R (2009). Sociology of sex work. Annual Review of Sociology, 35, 213–234.
Weitzer R (2012). Legalizing prostitution: From illicit vice to lawful business. NYU Press.
Williams DR, Neighbors HW, & Jackson JS (2003). Racial/ethnic discrimination and health: findings
from community studies. American journal of public health, 93(2), 200–208. [PubMed: 12554570]
Wilson HW, & Widom CS (2010). The role of youth problem behaviors in the path from child abuse
and neglect to prostitution: A prospective examination. Journal of Research on Adolescence,
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Wirtz AL, Peryshkina A, Mogilniy V, Beyrer C, & Decker MR (2015). Current and recent drug use
intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian
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Zheng T (Ed.). (2010). Sex trafficking, human rights, and social justice (pp.10). New York: Routledge.
Sawicki et al. Page 17
Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.
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http://www.unaids.org/sites/default/files/media_asset/06_Sexworkers
https://swp.urbanjustice.org/sites/default/files/RevolvingDoorES
http://www.surgeongeneral.gov/library/mentalhealth/home.html
http://www.surgeongeneral.gov/library/mentalhealth/home.html
https://2001-2009.state.gov/r/pa/ei/rls/38790.htm
https://www.doi.gov/ocl/human-trafficking
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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https://doi.org/10.1371/journal.pmed.1002680
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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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Health impact of sex work legislation
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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)
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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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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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)
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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)
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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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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].
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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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
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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)
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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)
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.t002
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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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)
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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)
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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. 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PMID: 11297308 Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 53 / 54 https://doi.org/10.1080/07399330902733281 http://www.ncbi.nlm.nih.gov/pubmed/19191121 https://doi.org/10.1007/s10903-016-0399-x https://doi.org/10.1007/s10903-016-0399-x http://www.ncbi.nlm.nih.gov/pubmed/27015834 https://doi.org/10.1186/1744-8603-9-33 http://www.ncbi.nlm.nih.gov/pubmed/23889941 https://doi.org/10.1080/09540121.2014.970504 https://doi.org/10.1080/09540121.2014.970504 http://www.ncbi.nlm.nih.gov/pubmed/25360822 https://doi.org/10.1136/bmj.a811 https://doi.org/10.1136/bmj.a811 http://www.ncbi.nlm.nih.gov/pubmed/18667468 https://doi.org/10.1111/j.1467-9566.2008.01112.x http://www.ncbi.nlm.nih.gov/pubmed/19144087 https://doi.org/10.1111/j.1467-9566.2010.01276.x https://doi.org/10.1111/j.1467-9566.2010.01276.x http://www.ncbi.nlm.nih.gov/pubmed/21226729 https://doi.org/10.1186/s12914-018-0149-3 http://www.ncbi.nlm.nih.gov/pubmed/29394893 https://doi.org/10.1080/00224499.2017.1393652 https://doi.org/10.1080/00224499.2017.1393652 http://www.ncbi.nlm.nih.gov/pubmed/29148837 https://doi.org/10.1016/S0140-6736(14)60800-X https://doi.org/10.1016/S0140-6736(14)60800-X http://www.ncbi.nlm.nih.gov/pubmed/25059943 http://www.ncbi.nlm.nih.gov/pubmed/25006086 https://doi.org/10.1111/j.1468-4446.2007.00136.x http://www.ncbi.nlm.nih.gov/pubmed/17343635 https://doi.org/10.1016/S0140-6736(12)60920-9 https://doi.org/10.1016/S0140-6736(12)60920-9 http://www.ncbi.nlm.nih.gov/pubmed/22819652 https://doi.org/10.1111/j.1753-6405.2010.00594.x http://www.ncbi.nlm.nih.gov/pubmed/21040176 https://doi.org/10.1002/hec.3791 http://www.ncbi.nlm.nih.gov/pubmed/29978530 http://www.ncbi.nlm.nih.gov/pubmed/24670587 http://www.ncbi.nlm.nih.gov/pubmed/11297308 https://doi.org/10.1371/journal.pmed.1002680 146. Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global under- standings of HIV prevalence. Glob Public Health. 2016; 11(7–8):849–65. https://doi.org/10.1080/ 17441692.2016.1181193 PMID: 27173599 147. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and con- siderations for implementation and scale-up. Lancet. 2015; 385(9963):172–85. https://doi.org/10. 1016/S0140-6736(14)60973-9 PMID: 25059938 148. Cornish F, Campbell C. The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa. Am J Community Psychol. 2009; 44(1–2):123–35. https://doi.org/10.1007/s10464-009-9254-8 PMID: 19521765 149. World Health Organization. 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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680.t001
https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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https://doi.org/10.1371/journal.pmed.1002680
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
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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)
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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)
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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)
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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
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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
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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)
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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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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.t002
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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https://doi.org/10.1371/journal.pmed.1002680.g002
https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g003
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https://doi.org/10.1371/journal.pmed.1002680
(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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
Public Access Author m
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Published in final edited form
as:
Sex Relation Ther. 2019 ; 34(3): 355–371. doi:10.1080/14681994.2019.1574970.
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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Sawicki et al. Page 17
Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.
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http://www.unaids.org/sites/default/files/media_asset/06_Sexworkers
https://swp.urbanjustice.org/sites/default/files/RevolvingDoorES
http://www.surgeongeneral.gov/library/mentalhealth/home.html
http://www.surgeongeneral.gov/library/mentalhealth/home.html
https://2001-2009.state.gov/r/pa/ei/rls/38790.htm
https://www.doi.gov/ocl/human-trafficking
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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https://doi.org/10.1371/journal.pmed.1002680
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
Health impact of sex work legislation
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Fig 1. Flow chart of included qualitative and quantitative studies. SWs, sex workers.
https://doi.org/10.1371/journal.pmed.1002680.g001
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
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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
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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
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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
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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
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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
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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)
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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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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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)
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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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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
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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)
Health impact of sex work legislation
PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 16 / 54
https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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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)
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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)
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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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Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global under- standings of HIV prevalence. Glob Public Health. 2016; 11(7–8):849–65. https://doi.org/10.1080/ 17441692.2016.1181193 PMID: 27173599 147. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and con- siderations for implementation and scale-up. Lancet. 2015; 385(9963):172–85. https://doi.org/10. 1016/S0140-6736(14)60973-9 PMID: 25059938 148. Cornish F, Campbell C. The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa. Am J Community Psychol. 2009; 44(1–2):123–35. https://doi.org/10.1007/s10464-009-9254-8 PMID: 19521765 149. World Health Organization. Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries. Recommendations for a public health approach. Geneva: World Health Organization; 2012. 150. Agata D, Stevenson L. Nothing about us without us! Amsterdam: International Committee on the Rights of Sex Workers in Europe; 2015. Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 54 / 54 https://doi.org/10.1080/17441692.2016.1181193 https://doi.org/10.1080/17441692.2016.1181193 http://www.ncbi.nlm.nih.gov/pubmed/27173599 https://doi.org/10.1016/S0140-6736(14)60973-9 https://doi.org/10.1016/S0140-6736(14)60973-9 http://www.ncbi.nlm.nih.gov/pubmed/25059938 https://doi.org/10.1007/s10464-009-9254-8 http://www.ncbi.nlm.nih.gov/pubmed/19521765 https://doi.org/10.1371/journal.pmed.1002680
Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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
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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)
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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)
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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
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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
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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)
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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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https://doi.org/10.1371/journal.pmed.1002680
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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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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https://doi.org/10.1371/journal.pmed.1002680.g002
https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g003
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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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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https://doi.org/10.1371/journal.pmed.1002680
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
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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)
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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)
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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)
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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)
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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)
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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)
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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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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.t002
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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https://doi.org/10.1371/journal.pmed.1002680.g002
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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.
https://doi.org/10.1371/journal.pmed.1002680.g003
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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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
Public Access Author m
anuscript
Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.
Published in final edited form
as:
Sex Relation Ther. 2019 ; 34(3): 355–371. doi:10.1080/14681994.2019.1574970.
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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uthor M
anuscript
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A
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uthor M
anuscript
http://www.unaids.org/sites/default/files/media_asset/06_Sexworkers
https://swp.urbanjustice.org/sites/default/files/RevolvingDoorES
http://www.surgeongeneral.gov/library/mentalhealth/home.html
http://www.surgeongeneral.gov/library/mentalhealth/home.html
https://2001-2009.state.gov/r/pa/ei/rls/38790.htm
https://www.doi.gov/ocl/human-trafficking
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g001
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
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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)
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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)
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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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Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global under- standings of HIV prevalence. Glob Public Health. 2016; 11(7–8):849–65. https://doi.org/10.1080/ 17441692.2016.1181193 PMID: 27173599 147. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and con- siderations for implementation and scale-up. Lancet. 2015; 385(9963):172–85. https://doi.org/10. 1016/S0140-6736(14)60973-9 PMID: 25059938 148. Cornish F, Campbell C. The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa. Am J Community Psychol. 2009; 44(1–2):123–35. https://doi.org/10.1007/s10464-009-9254-8 PMID: 19521765 149. World Health Organization. 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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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].
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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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
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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)
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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)
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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
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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
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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
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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
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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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https://doi.org/10.1371/journal.pmed.1002680
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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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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https://doi.org/10.1371/journal.pmed.1002680
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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Perez-Brumer AG, Oldenburg CE, Reisner SL, Clark JL, Parker RG. Towards ‘reflexive epidemiology’: conflation of cisgender male and transgender women sex workers and implications for global under- standings of HIV prevalence. Glob Public Health. 2016; 11(7–8):849–65. https://doi.org/10.1080/ 17441692.2016.1181193 PMID: 27173599 147. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and con- siderations for implementation and scale-up. Lancet. 2015; 385(9963):172–85. https://doi.org/10. 1016/S0140-6736(14)60973-9 PMID: 25059938 148. Cornish F, Campbell C. The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa. Am J Community Psychol. 2009; 44(1–2):123–35. https://doi.org/10.1007/s10464-009-9254-8 PMID: 19521765 149. World Health Organization. Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries. Recommendations for a public health approach. Geneva: World Health Organization; 2012. 150. Agata D, Stevenson L. Nothing about us without us! Amsterdam: International Committee on the Rights of Sex Workers in Europe; 2015. Health impact of sex work legislation PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 54 / 54 https://doi.org/10.1080/17441692.2016.1181193 https://doi.org/10.1080/17441692.2016.1181193 http://www.ncbi.nlm.nih.gov/pubmed/27173599 https://doi.org/10.1016/S0140-6736(14)60973-9 https://doi.org/10.1016/S0140-6736(14)60973-9 http://www.ncbi.nlm.nih.gov/pubmed/25059938 https://doi.org/10.1007/s10464-009-9254-8 http://www.ncbi.nlm.nih.gov/pubmed/19521765 https://doi.org/10.1371/journal.pmed.1002680
Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680.t001
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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.
https://doi.org/10.1371/journal.pmed.1002680.g001
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https://doi.org/10.1371/journal.pmed.1002680
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
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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)
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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)
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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)
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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
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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
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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)
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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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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.t002
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https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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https://doi.org/10.1371/journal.pmed.1002680.g002
https://doi.org/10.1371/journal.pmed.1002680
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.
https://doi.org/10.1371/journal.pmed.1002680.g003
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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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Culturally Competent Health Care for Sex Workers: An
Examination of Myths That Stigmatize Sex-Work and Hinder
Access to Care
Danielle A. Sawicki1, Brienna N. Meffert1, Kate Read2, Adrienne J. Heinz1,3
1National Center for Posttraumatic Stress Disorder, Veterans Affairs Palo Alto Healthcare System
2Black Dot Writing LLC, Veterans Affairs Palo Alto Healthcare System
3Center for Innovation to Implementation, Veterans Affairs Palo Alto Healthcare System
Sex workers are individuals who offer sexual services in exchange for compensation (i.e., money,
goods, or other services). Within the United States the full-service sex work (FSSW) industry
generates 14 billion dollars annually there are estimated to be 1-2 million FSSWers, though
experts believe this number to be an underestimate. Many FSSWers face the possibility of
violence, legal involvement, and social stigmatization. As a result, this population experiences
increased risk for mental health disorders. Given these risks and vulnerabilities, FSSWers stand to
benefit from receiving mental health care however a constellation of individual, organizational,
and systemic barriers limit care utilization. Destigmatization of FSSW and offering of culturally
competent mental health care can help empower this traditionally marginalized population. The
objective of the current review is to (1) educate clinicians on sex work and describe the unique
struggles faced by FSSW and vulnerability factors clinicians must consider, (2) address 5 common
myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
clinical training agenda that can optimize mental health care engagement and utilization within the
sex
work community.
Keywords
sex work; sex workers; prostitution; mental health; stigma; trauma
The sex industry, in varying forms and degrees, has been in existence for centuries. Attitudes
about sex work have evolved based on political and economic climates, predominant
religious beliefs, and law enforcement efforts. The term “sex work” is an umbrella term for
the provision of sexual services or performances by one person for which a second person,
the client or customer, provides money or other markers of economic value (i.e., goods,
services). Sex work refers to prostitutes, escorts, strippers, porn actors, sex phone operators,
or dominatrixes. It should be noted that not all people who participate in these acts identify
as sex workers. In sex work research, there is a long-standing debate about utilizing
Correspondence for this article should be addressed to Dr. Adrienne J. Heinz, 795 Willow Rd. (152-MPD), Menlo Park, CA 94025.
adrienneheinz@gmail.com.
U.S. Department of Veterans Affairs
Public Access Author m
anuscript
Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.
Published in final edited form
as:
Sex Relation Ther. 2019 ; 34(3): 355–371. doi:10.1080/14681994.2019.1574970.
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terminology such as “sex work” versus “prostitution.” We use “sex work” here to emphasize
the labor aspect of commercial sex and find it to be a less pejorative and gendered term. It is
important to distinguish between sex workers who do and do not have in-person contact with
clients, as individuals who meet with clients in-person face more legal and safety risks. For
this article, the term full-service sex worker (FSSW), refers specifically to individuals who
provide in-person sex services. The Center for Disease Control (CDC; 2016) defines FSSW
as:
“Escorts; people who work in massage parlors, brothels, and the adult film
industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women,
and transgender persons who participate in survival sex, i.e., trading sex to meet
basic needs of daily life. For any of the above, sex can be consensual or
nonconsensual.”
This definition is fallacious, as anything that is not consensual is not part of what has been
agreed upon in terms of services and labor, therefore it enters into the realm of assault. Like
other forms of work or labor, FSSW involves choice and consent among those involved. As
of 2017, 72% of adolescents and 65% of adults reported high levels of trust in the CDC
(Kowitt, Schmidt, Hannan, & Goldstein, 2017). The conflation of assault and FSSW in a
trusted government organization highlights the need for a deeper understanding of
consensual FSSW as it has significant implications for policy and practice.
The FSSW trade in the United States generates about $14 billion annually (Havoscope,
2013). A 2012 report by Fondation Scelles indicated that there were an estimated 40-42
million FSSWers in the world, 1-2 million of which were in the U.S. Importantly, little is
known about the actual size of this population, as most studies of FSSW rely on samples of
convenience, typically recruiting in jails, clinics that treat sexually transmitted infections,
and opioid use disorder treatment programs, and many individuals may elect to not disclose
their work status for fear of stigma. FSSW is criminalized in the U.S. and most countries,
and as such, registries of FSSWers are not available.
Many studies conflate sex trafficking and FSSW, which renders it more difficult to estimate
the prevalence of either group. Sex trafficking is a human rights violation involving threat or
the use of force, abduction, deception, or other forms of coercion to exploit individuals. This
may include forced labor, sexual exploitation, slavery, and more. FSSW, in contrast, is a
consensual transaction between adults, where the act of selling or buying sexual services is
not a violation of human rights. It is important to note that many FSSWers believe that these
two points of nonconsensual and consensual FSSW are more of a continuum of free choice
rather than a dichotomy. FSSW itself is not a form of sexual violence, but FSSWers are
especially vulnerable to sexual and intimate partner violence.
The objective of the current review is to (1) provide education on the unique struggles faced
by FSSWers and vulnerability factors clinicians must consider, (2) address 5 common myths
about FSSW that perpetuate stigma, and (3) advance a research and culturally competent
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clinical training agenda that can help optimize mental health care engagement and utilization
within the sex work community.
FSSW, Violence, and Trauma Exposure
Violence against FSSWers is pervasive and represents a significant public health concern.
Conflation of sexual violence with FSSW can increase violence against FSSWers by
perpetuating stigma (Lowman, 2000) and this is because stigma can alienate FSSWers from
social services (UNAIDS, 2014). Previous studies have noted a robust positive relationship
between anti-sex work rhetoric, which characterizes outdoor workers as a nuisance or threat
to public order, and an increase in violence against sex workers (Lowman, 2000).
Criminalization and policing, population movement and mobility, work environments,
broader economic conditions and gender inequality are also correlated with increased
violence against FSSWers (Deering et al., 2014). Additionally, prior research has shown that
adolescents who are homeless (Shannon, 2009), individuals who has previously been
arrested for FSSW (Cohan et al., 2006), migrant FSSW (Reed, Gupta, Biradavolu, &
Blankenship, 2012), FSSW who use drugs (Wirtz, Peryshkina, Mogilniy, Beyrer, & Decker,
2015), and outdoor (i.e., street-based) FSSWers (Weitzer, 2009) were at especially high risk
of violence.
The magnitude of violence experienced by this population is profound and one in five police
reports of sexual assault from an urban, U.S. emergency room were filed by FSSWers
(Mont, 2008). In Phoenix, Arizona 37% of FSSWers diversion program participants report
being raped by a client, and 7.1% report being raped by a pimp (Schepel, 2011). In Miami,
Florida, 34% of outdoor FSSWers had reported violent encounters with clients in the past 90
days of being interviewed (Surratt, 2011). In New York, 46% of indoor FSSWers (i.e.,
individuals who work in hotels, brothels, homes, or other indoor areas) reported being forced
to do something by a client that they did not want to do (Thukral, 2005), and over 80% of
outdoor FSSWers experienced violence (Urban Justice Center, 2003).
Exposure to institutionalized violence and discrimination.—FSSWers are
especially vulnerable to police violence, and there are several documented cases of this
throughout the United States. Police officers have been documented to threaten victims with
arrest or stage an arrest and sexually assault victims. Seventeen percent of FSSWers
interviewed in a New York study reported sexual harassment and abuse, including rape, by
police (Urban Justice Center, 2003). In a Chicago study, 24% of outdoor FSSWers who had
been raped identified a police officer as the perpetrator (Raphael & Shapiro, 2002).
Frequently FSSWers are not protected by rape shield laws. Although New York and Ohio
explicitly exclude FSSW to be used as character evidence against rape victims, judges in
states without explicit exclusion of FSSW often allow for FSSW to be brought up in order to
invalidate assault charges. FSSWers may also be arrested when they report violence,
including trafficking, to the police because, even though the FSSWers are victims of
violence, they are still criminalized. Additionally, FSSWers receive more victim blame and
less empathy after experiencing a sexual assault in comparison to the general population
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(Sprankle, Bloomquist, Butcher, Gleason, & Schaefer, 2018). Accordingly, many FSSWers
are unlikely to trust or engage with public safety systems as these very systems have failed
to keep them or their colleagues safe, and have even done further harm.
Unaddressed Mental Health Needs and Barriers to Care Engagement
The pervasive violence against FSSWers creates an increased risk of mental health
conditions. Prior research demonstrates that posttraumatic stress disorder (PTSD) is
especially common after traumatic events involving physical and sexual violence (Liu et al.,
2017). In addition to physical and sexual violence, FSSWers are also at greater risk to use
and experience problems with substances than in the general population (Burnette et al.,
2008; Nuttbrock, Rosenblum, Magura, Villano, & Wallace, 2004). The use of substances to
cope with violence and discrimination may explain the higher rate of substance use
problems in FSSW. Indeed, prior substance use research shows that using substances to cope
with negative affect is the best predictor of having or developing a problem (Martens et al.,
2008). In turn, substance use poses a risk for other health problems as well, such as HIV and
other sexually transmitted infections (Hwang, Ross, Zack, Bull, Rickman, & Holleman,
2003). Importantly though, there has been far more clinical attention paid to sexually
transmitted infections (STIs) among FSSWers than to their mental health struggles.
Indeed, there is a dearth of research focused on the mental health of FSSWers (Rössler et al.,
2010). Extant studies have offered important first steps but have tended to only focus on
single conditions like PTSD, depression, or drug use. These prior works did not use
diagnostic criteria, dealt exclusively with selected work settings like outdoor FSSWers, or
were predominantly concerned with violence by customers towards FSSWers (Rössler et al.,
2010). A 2001 study found that 59% of the 193 interviewed FSSWers reported they needed
therapeutic or emotional support from others on the street and 57% said they needed
professional counselling (Valera, 2001). Additionally, a 2010 study of FSSWers observed
higher rates of mental illnesses than seen in the general public, such as PTSD (13%), anxiety
(33.7 %) and major depression (24.4%) (Rössler et al., 2010). In contrast, an estimated
3.6%, 19.1%, and 6.7% of American adults experience clinical PTSD, generalized anxiety
disorder, or depression in 2017 (National Institute of Mental Health, 2018). FSSWers are
therefore at a much greater risk for mental health conditions but often experience barriers to
seeking treatment, such as lack of access to health insurance and general distrust of medical
professionals due to sigma, work invalidation, and potential misogyny (Noyes, 2013; Varga
& Kalash KaFae Magenta Fire, 2018).
Given this constellation of challenges, it is critical that FSSWers have access to competent
and culturally sensitive mental health care to help empower them, and to reduce their risk of
victimization and engagement in risky behaviors. For clinicians to provide culturally
competent care to FSSWers, it is critical to understand why FSSW is stigmatized and how
that stigma perpetuates social inequities.
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1. FSSW Should Be Criminalized
There are several government models for regulating FSSW including criminalization, partial
criminalization, legalization, and decriminalization (see Basil, 2015; Mac, 2016). Currently,
the majority of countries, such as the U.S., operate under a partial or fully criminalized
model of FSSW. In the U.S., other than Nevada, FSSW is illegal. Importantly, in the U.S.,
sex workers that do not engage in physical intercourse (i.e., escorts, strippers, sex phone
operators, dominatrixes) are not subjected to the same penalties that FSSWers face, but still
face regulations that can result in criminal charges. Legalization and decriminalization
models are now seen in countries like Germany, the Netherlands, and New Zealand.
Legalization.—Legalization in other countries commonly means that FSSW is regulated
with laws regarding where, when, and how FSSW may take place. Importantly, legalization
still criminalizes those FSSWers who cannot or will not fulfil various bureaucratic
responsibilities. For example, in Nevada, FSSW that occurs in a sanctioned brothel is legal
while all other forms of FSSW are outlawed. Businesses and individuals involved in FSSW
face regulations and licensing procedures that other businesses do not. FSSWers must
register with the police department as a brothel worker and face restricted mobility,
stipulated working conditions, mandated testing for gonorrhoea, chlamydia, HIV and
syphilis, and more (see NAC 441A.777 to 441A.815). These regulations also
disproportionately affect FSSWers who are already marginalized, like people who use
substances or who are undocumented.
Decriminalization.—In contrast to legalized models of FSSW, decriminalization means
that the criminal penalties attributed to an act are no longer in effect and that the same laws
that regulate other businesses regulate FSSW. Unlike legalization, a decriminalized system
does not have special laws aimed solely at FSSW or sex work-related activity. This
particular model is practiced in New Zealand. In 2003, New Zealand passed the Prostitution
Reform Act (PRA) which acknowledged that FSSW is service work and allows FSSWers to
operate under the same employment and legal rights accorded to any other occupational
group.
A common argument against legalizing or decriminalizing FSSW assert that in places where
the work is legalized or tolerated, there is a greater demand for human trafficking victims
and human trafficking investigations are hampered (U.S. Department of State, Bureau of
Public Affairs, 2004). Furthermore, many believe that the presence of FSSW increases crime
and violence (e.g., drug dealing, assaults and robberies) and that the practice creates higher
levels of vulnerability, exploitation, and coercion that contribute to trafficking (Coté, 2008;
U.S. Department of the Interior, 2017). Opposingly, Law (1999) argues that
decriminalization of FSSW facilitates regulation that reduces exploitation of FSSWers. For
instance, by enabling FSSWers to make complaints without fear of prosecution, abuse and
trafficking can be more easily exposed and tracked (Law, 1999). Others who support the
decriminalization of FSSW focus on the negative consequences of criminalization and
stigmatization on the life and working conditions of FSSWers. They conclude that
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https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec777
https://www.leg.state.nv.us/NAC/NAC-441A.html#NAC441ASec815
decriminalization is necessary to improve these negative consequences and conditions (e.g.,
Brock, 1998; Delacoste & Alexander, 1998; Ditmore, 2010; Canadian HIV/AIDS Legal
Network, 2005), especially because evidence suggests that the issue of trafficking has been
grossly exaggerated (Harcourt & Donovan, 2005; Hubbard, Matthews, & Scoular, 2008;
Davidson, 2006; Weitzer, 2007). The conflation of consensual FSSW and human trafficking
causes imprecise estimation of trafficking victim rates and increases the likelihood of
exaggeration (Tyldum & Brunovskis, 2005).
Recent policy changes in the U.S. include the Stop Enabling Sex Traffickers Act (SESTA)
and Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA). These policies
seek to stop the assistance, facilitation, or support for sex trafficking by making website
providers liable for any usage of their platforms that facilitates sex trafficking, knowingly or
unknowingly. The bills conflate FSSW and sex trafficking by targeting websites that
promote FSSW without differentiating between consensual FSSW and trafficking. This in
turn, harms both FSSWers and trafficking victims. Research in New Zealand demonstrates
that prior to decriminalization, the FSSW industry showed an industry vulnerable to
exploitation, coercion, and violence (Plumridge, 2001; Plumridge & Abel, 2000; Plumridge
& Abel, 2001). With new policies such as FOSTA-SESTA, it may become harder for
trafficking victims to be identified as they will be pushed offline and further underground
(Fischer, 2018; Zheng, 2010) and can directly impact the lives of FSSWers (Agustín, 2010;
Desyllas, 2007; Doezema, 1998; Katsulis, 2009; Katsulis, Weinkauf, & Frank, 2010).
Furthermore, since FOSTA-SESTA fails to differentiate between FSSW and trafficking,
websites used by FSSWers to protect themselves, such as blacklists (i.e., lists of clients who
have historically been violent, pushed boundaries, stolen from FSSWers, or refused to pay)
have been removed.
Many FSSWers believe legalization would destigmatize their work and make it safer (Read,
2013). However, some acknowledge that legalization simply makes the government their
“pimp” and question the impact of future employment prospects in “straight jobs” if their
name is located in a FSSW database. Decriminalizing FSSW seems to have more support
within the FSSW community as it makes arresting FSSWers a low-priority among law
enforcement and allows the trade to continue with little to no government interference
(Read, 2013). Detractors feel this does not offer enough protections for workers, but
supporters feel it offers them the freedom and anonymity that they desire when operating in
such a highly stigmatized profession.
2. FSSW Cannot Be A Feminist Choice
The vast majority of FSSW discourse (i.e., how it is written and/or spoken about) is steeped
in a long, complex, and highly gendered historical context. Historically, FSSW discourse
established “prostitution” as a female occupation in service to male clientele. This had led,
in part, to classifying female FSSWers as vectors of disease, erasing male and transgender
FSSWers all together, stigmatizing and criminalizing FSSW throughout many parts of the
world, and establishing that FSSW simply cannot be a feminist choice. These pervasive
stereotypes still influence contemporary ideas about FSSW and have emotional and material
consequences for all FSSWers.
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It should be noted that there are various types of feminism, including (though not limited to)
radical, liberal, socialist, marxist, and cultural feminism. These forms of feminism examine
gender through a male/female binary. The two foundational feminisms are “radical” and
“liberal” and they work in direct opposition to each other’s ideologies in many ways.
Radical and liberal feminist discourse has dominated discussions around FSSW, but a new
era of intersectional feminism has introduced a new lens through which to see FSSW.
Radical feminism (also referred to as “second wave feminism”) was cutting-edge feminist
theory in the 1960s and 1970s that gained momentum in the 1980s. It is best described as the
philosophy that men have systematically oppressed women in myriad ways, from bras to sex
trafficking, and that women-only spaces and organizations were necessary to negate this
subjugation. Radical feminists wanted to eliminate male supremacy and were frequently
referred to as “man-haters.” The radical feminist discourse aligns well with the traditional
gendered discourse around FSSW that women are perpetual victims of male domination,
which aligns with our gendered history where women are assumed to be weak and victims,
while men were assumed to be empowered and perpetrators.
Liberal feminism (also referred to as “third wave feminism”) arguably began with the
suffrage movement and is the philosophy that women are equal to men and can maintain
equality through their personal actions and choices. More recently, liberal feminism has
pushed back against the radical feminist narrative by suggesting that women have agency
and therefore can choose FSSW as an occupation and that choosing FSSW can be
empowering, as long as the worker and the client are consenting adults.
Much of the feminist debate around FSSW revolves around the question of whether FSSW
constitutes a form of involuntary sexual objectification [radical feminist perspective] or
voluntary sexual labor [liberal feminist perspective] (Read, 2013). Both the radical and
liberal feminist FSSW discourses are problematic as they are predicated on a male/female
gender binary that constructs the female as the sexual service provider and the male as the
client.
More recently, intersectional feminism has come to the forefront (Crenshaw, 1989) which
points to the inherent racism and classism in other, former feminist movements that have
been traditionally led by privileged, white women and argues that not all women have the
same discriminatory experiences. For example, while white women may experience gender
discrimination, women of color experience gender discrimination compounded by racial
discrimination. The Combahee River Collective, a group of Black feminists, wrote a
manifesto that has been cited as one of the earliest expressions of intersectionality. They
argued, “We […] find it difficult to separate race from class from sex oppression because in
our lives they are most often experienced simultaneously” (Combahee River Collective,
1977/1995, p. 234). Intersectional feminism has opened the feminist conversation to include
class, race, sexual orientation, gender, age, and dis/ability. This is important because it
highlights different experiences within specific categories (i.e., “women” can be women of
color, transwomen, women of various ages and abilities) and appreciates the complexity
within their experiences. This idea then translates to a more layered understanding of various
experiences and occupations, including FSSW. Increased focus on communities that
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experience marginalization based on membership of multiple categories (ex: race, class,
gender, sexual identity) is therefore necessary (Cole, 2009).
Using intersectional feminism as an analytical framework, some scholars have aimed to push
the liberal feminist perspective forward by addressing male and transgender FSSWers
acknowledging that vulnerability and harm co-exist with autonomy and agency in FSSW.
FSSW, like most work, is not a homogenous experience. Recent scholarship discusses
FSSW as a choice for women, men, and the trans community. Smith and Laing (2012)
summarize the literature as having “done much to expose and challenge the entrenched
polarities–such as those between oppression and liberation, violence and pleasure, and
victimhood and agency–that have long underpinned political and philosophical debates
surrounding the sale and purchase of sex” (p.517). FSSW is complex and the people
performing the work have widely varying degrees of satisfaction with it, just as those in
other professions might.
FSSW: A Feminist Choice.—So, how can FSSW be feminist? Simply put, choosing
FSSW establishes a person’s ability to make a choice about their own body, which is at the
heart of all feminist movements. Choosing FSSW establishes that all people have agency
and the right to choose whatever occupation they want. To be clear, even the idea of
“choice” is complicated. For example, a single dad may have to choose between working 60
hours at a call center, making minimum wage and barely seeing his children all week or
choosing FSSW where he will make the same amount of money working only 10 hours per
week, having a flexible schedule and see his children. Detractors argue that FSSW is
exploitive to the (female) body and puts (female) FSSWers in harm’s way. Arguably, many
physically demanding occupations have similar stakes (firefighters, professional football
players), yet there is no stigma around those predominantly male occupations. In part, this is
born out of the anti-feminist notion that men are somehow more capable of making
decisions about their bodies than women. An important aspect to note about FSSW, as with
any work, is that sometimes providers like their job, sometimes they hate it, sometimes they
do it as a last resort, sometimes they do it because it is enjoyable, and everything in between.
What sets FSSW apart from other forms of work is that it is criminalized and highly
stigmatized and this has material consequences for the worker.
3. All FSSWers Are Equally Impacted By Stigma
Comprehensive literature reviews and reports from government agencies conclude that
stigma exerts multiple negative effects on social status, psychological well-being, and
physical health (e.g., Major & O’Brien, 2005; U.S. Department of Health and Human
Services, 1999; Williams, Neighbors, & Jackson, 2003). Members of stigmatized groups are
discriminated against in the housing market, workplace, educational settings, healthcare, and
the criminal justice system (Crandall & Eshleman, 2003; Sidanius & Pratto, 1999). In the
case of FSSW, this identity is often concealed because of stigma. A concealed stigmatized
identity, although kept hidden from others, carries with it social devaluation (Crocker, Major,
& Steele, 1998).
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When clinically assessing a FSSWer’s risk for negative outcomes related to stigma, it is
paramount to appreciate the ways in which race, class, gender, and sexual identity can affect
an individual’s experience. A middle-class white outdoor cisgender female worker will be at
lower risk than an outdoor black transwoman or a lower income Latinx immigrant worker. In
comparison to the general population, FSSWers are overall at higher risk for violence, stress,
low self-esteem, depression, suicide, substance use, disease, malnutrition, family
estrangement, police harassment and profiling, stress from intimate partners, and job
insecurity (Varga & Kalash KaFae Magenta Fire, 2018). Much of this can be tied into the
stigma FSSWers face within society “in the wild” and what happens when marginalized
identities intersect.
FSSWers face different levels of discrimination both from their own community and society
as a whole due to whorephobia. Whorephobia is defined by professionals in the sex work
industry as “the fear or hate of sex workers” although, along with other forms of oppression,
it can be applied on a structural basis. The term whorephobia is used to denote forms of
hatred, disgust, discrimination, violence, aggressive behavior or negative attitudes directed at
individuals who are engaged in sex work. Whorephobia operates in several contexts,
resulting in excessive forms of violence, institutional discrimination, criminalization and all
other negative and hostile environments that target sex workers. Whorephobia, also tends to
hold the most consequences for women. In the majority of languages, the most common
sexist insults are “whore” or “slut,” which makes women want to distance themselves from
the stigma associated with those words, and from those who incarnate it. It is believed that
the ‘whore stigma’ is a way to control women and to limit their autonomy – whether it is
economic, sexual, professional, or simply freedom of movement. Women and men are
brought up to think of sex workers as “bad women”. It prevents women from copying and
taking advantage of the freedoms sex workers fight for, like the occupation of nocturnal and
public spaces, or how to impose a sexual contract in which conditions have to be negotiated
and respected. The stigma that FSSWers carry with them can, at its worst, be fatally
dangerous as they are 18 times more likely to be murdered compared to the rest of the
population (Potterat et al., 2004).
An additional form of marginalization FSSWers face due to whorephobia is based within the
‘whorearchy’. The whorearchy is arranged according to intimacy of contact with clients as
well as intersections of other marginalized identities. The more marginalized and closer in
contact one is to a client, the closer they are to the bottom of the whorearchy (Bosch, 2016).
That puts outdoor FSSWers at the bottom. They are often looked down upon by indoor
FSSWers, who find clients online or via other third parties. Indoor FSSWers are looked
down upon by strippers and escorts who only perform sex fantasies for clients but do not
include full service contact. At the top sit sex workers who have no direct contact with
clients, such as cam girls (i.e web-camera) and phone-sex operators. This means that the
lower an individual is in the whorearchy, the more stigma they face both from internal
community and society more broadly. Survival FSSWers, who are often outdoor workers,
carry a far greater risk of developing depression, psychiatric hospitalization, and workers are
4.5 times more likely to attempt suicide (Anklesaria & Gentile, 2012).
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Unfortunately, male and transgender FSSWers have been historically underrepresented in
discussions of sex work, and to date there is still very little research on this sub-population
that does not have a medical agenda. Specially, contemporary research on male FSSWers
typically has focused on men and HIV transmission or male sex workers and HIV/AIDS.
Yet, with little qualitative data analysis to contextualize the quantitative medical data
collected, it is difficult to gather an accurate depiction of the everyday lived realities of male
and transgender FSSWers. This dearth of knowledge is problematic as of the estimated
40-42 million FSSWers in the global economy, 8-8.42 million are cisgender men, meaning
that about 1 in 5 of FSSWers are cisgender men (Minichiello & Scott, 2017).
4. All Sex Workers Experienced Childhood Trauma
Research findings are mixed regarding whether FSSWers are more apt to have traumatic
pasts in comparison to the general population. An extensive body of literature argues that
working in the sex industry is the result of negative experiences in early stages of the life
course (i.e., childhood, adolescence, and emerging adulthood). According to the oppression
paradigm, a paradigm that assumes that FSSW is an “expression of patriarchal gender
relations and male domination” (Weitzer, 2012, p. 10), childhood sexual abuse and other
sources of trauma are common early life contributors to FSSW (Simons & Whitbeck, 1991;
Stoltz et al., 2007; Wilson & Widom, 2010). A smaller set of studies argues that people’s
current economic opportunities, needs, and other situational adult factors better explains
their involvement in FSSW. Yet, most research on FSSW has used data gathered from small
samples and assumed, but has not demonstrated, that their needs and motives are different
from people employed elsewhere.
On average, a greater proportion of people employed in the sex industry had many of the
early life course experiences—from childhood poverty and abuse, to homelessness—that the
oppression paradigm cites as contributing factors to sex work (McCarthy, Benoit, & Jansson,
2014). However, the data also indicated that, compared to people who worked in other
service/care jobs, a greater proportion of those involved in FSSW had lower levels of human
capital and less education and, on average, had worked in fewer occupations (McCarthy,
Benoit, & Jansson, 2014). People employed in the sex industry were also less likely to have
an income-earning partner. Thus, there was some evidence of the factors highlighted by the
empowerment perspective; namely, that experiences in adulthood, as well as in earlier life
course stages, contributed to working in the industry (McCarthy, Benoit, & Jansson, 2014).
There is a risk of the intersection of childhood trauma and active trauma with this population
that creates the possibility of re-traumatization or repetition compulsion (i.e., the mind’s
tendency to repeat traumatic events in order to deal with them or change a previous
narrative) (Varga & Kalash KaFae Magenta Fire, 2018) that should be considered.
Additionally, previous research shows that childhood sexual trauma can be associated with
hypersexuality, more sexual curiosity, and exploration compared to individuals who had not
experienced childhood sexual trauma (Draucker et al., 2011). This data may support the
conclusion that early sexual trauma impacted a FSSWers choice to become a FSSWer.
Importantly, neither of these points invalidate a worker’s choice to do FSSW or the agency
the individual holds.
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Still, many individuals and clinicians within society believe that FSSWers need to be ‘saved’
from their work, especially if they come from abusive pasts. This concept is known as the
“savior complex” and this term has most often been employed in terms of white savior
complex when discussing persons of color and voluntourism (i.e., volunteer tourism). Savior
complex can happen in any community where an individual has more privilege than the
individual or community they are trying to serve. Given this power imbalance, it is
paramount to mindfully listen to marginalized voices and what the individual wants for
themselves.
5. FSSW Is Not Real Work
Different forms of FSSW (i.e., indoor versus outdoor, independent versus agency) involve
different forms of labor and risk. An indoor, independent FSSWer is often responsible for
creating their own media, marketing, websites, social media management, email
communications with clients, as well as screening clients to ensure safety. This process is
comparable to what an entrepreneur may go through when building their own business.
When with an agency, the individual FSSWer is generally not responsible for these
activities. Outdoor FSSWers are at highest risk, as they lack the online resources and
protection barriers that have become available in more recent years, such as blacklists.
Outdoor FSSWers, often ‘freestyle’ looking to meet potential clients either in bars, hotels, or
on the streets, which involves a different form of labor in comparison to independent indoor
and agency workers. Overall working hours, schedule stability, and the number of clients
seen can vary greatly depending on gender, socioeconomic status, and type of FSSW being
done. When looking at online advertisements for indoor independent FSSW, income varies
greatly, but many have one or two-hour minimums. Regardless of what type of work is being
done all FSSWers often perform both physical and emotional labor, the process by which
workers are expected to manage their feelings in accordance with organizationally defined
rules and guidelines. (Hochschild, 1983). Emotional labor may be listening to a client vent
about career, interpersonal, or psychological struggles. It can also look like offering support
or friendship to a client who is feeling upset. It has been said that individuals need to
perform similar emotional labor to therapists in this way (Varga & Kalash KaFae Magenta
Fire, 2018). It is crucial to note that because of how much labor, both emotional and
physical, FSSWers perform, self-care and recovery time is essential.
While some believe that all FSSWers only do this work because it is their only option for
survival, it is not the case for all. To place the entire community under this blanket
assumption further perpetuates the narrative that FSSWers have no agency and that this work
is not real work. In fact, the skills required to be a successful FSSWer can often be
transferred into other fields such as marketing, customer service, project management, and
office jobs such as legal or executive assistants. FSSWers may feel that their work gives
them the freedom to set their own schedules, have higher wages, and choose how to run their
own entrepreneurial business. These points are especially important to those who are
differently-abled or neurodivergent as the freedom FSSW provides them may be essential to
their well-being. Neurodivergent refers to neurodiversity, this movement neutralizes the
stigma that has traditionally been accorded to autism, ADHD, and other neurodevelopmental
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conditions. Many scholars extend the definition to include mental health differences. To this
portion of the community, FSSW can very well be a choice made out of personal preference.
Future directions for research and culturally competent clinical training for
serving sex workers
Future directions for research
This current review explores unique struggles faced by the sex work and FSSW community
and summarizes the literature to debunk myths that perpetuate stigma and harm towards the
community. These myths addressed include (1) that FSSW should be criminalized, (2) that
sex work is incompatible with feminism, (3) sex workers uniformly face the same level of
stigma, (4) sex workers gravitate to sex work due to childhood abuse, and (5) that sex work
isn’t real work.
Despite the burgeoning research on the mental health needs of FSSWers, there are many
shortcomings that must be addressed in order to better inform policy and best-practices for
culturally competent care. Specifically, there is little quantitative data to characterize the
different vulnerabilities sex workers face, and the preponderance of the literature reviewed
does not put the voices of sex workers first. That is, samples of convenience from drug
treatment or incarceration settings do not necessarily represent the experiences of all sex
workers. Further, given that FSSW is highly stigmatized as well as criminalized, researchers
need to determine how to overcome barriers to finding members of the community who are
willing to participate in research as they may perceive engagement with researchers to be
unsafe. More research is also required to explore the marginalization of sex workers from all
branches of the sex work force and to include representation of male, non-binary, trans, and
LGBTQA sex workers and not just cisgender women. Finally, thorough evaluation of the
costs, impacts, and outcomes of policies that regulate sex-trafficking (and sex work
indirectly), is sorely needed to determine whether such legislation yields the desired public
health and safety effects.
Consideration of multiple identifiers of marginalized populations will better enable
researchers to form a contextualized understanding of FSSWers experiences. This is
important because a focus on race, for example, without consideration of other category
memberships (e.e., sexuality, social-economic status, able-bodiedness) does not account for
the complexities or the layers of stigmas and vulnerabilities a person may hold if they have
multiple marginalized identities (Weber & Parra-Medina, 2003). Such attention to potential
nuances of intersecting marginalized identities is critical because failure to attend to how
social categories depend on one another for meaning renders knowledge of any one category
incomplete (Cole, 2009).
Clinical Recommendations
FSSWers face a multitude of barriers when it comes to accessing care, from stigma to
violence to criminalization. Due to fear of these barriers (i.e.,being stigmatized, violence, or
arrest) FSSWers often do not feel safe going to mental health clinicians. As a result of these
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barriers, FSSWers face higher rates of mental health struggles. As clinicians it is important
to recognize the needs and challenges of this community in order to better serve them.
Mental health providers can take several steps to offer culturally competent care. First, they
can remain client-centered even if their own values may not align with those of the client. It
is recommended that clinicians seek out consultation for any potential internal bias towards
or against sex work (Varga & Kalash KaFae Magenta Fire, 2018). Clinicians can also
employ trauma-informed care as FSSWers may have delayed reaction time to process trauma
due to stigma and shame. Third, clinicians can utilize a harm reduction approach in therapy
(Varga & Kalash KaFae Magenta Fire, 2018), such as removing barriers to entry for sex
workers seeking services and “meet them where they are” as well as focusing on the impact
of behaviors in a non-judgmental setting without discounting an individual’s agency. It can
also be beneficial to connect sex workers to bad date lists, resources where needles are
exchanged and/or supplies are provided (condoms, lubricant, clothes), and resources where
sex workers can find community and social support.
Developing culturally competent trainings—Provision of organizationally supported
mentorship by and consultation among mental health professionals will also function to
better serve the FSSW community. For instance, clinical trainings about the specific needs of
sex workers as well as working to move through biases can be offered to the mental health
community, such as graduate students and medical students as part of the curriculum, and to
first responders who may be in situations where they will need to provide care to sex
workers (ex: police and paramedics). A current successful training model is offered by
clinicians from St. James Infirmary, the nation’s only peer based occupational health and
safety clinic for sex workers. St. James Infirmary’s model focuses on teaching clinicians
about sex workers and ways in which they can support the community and approach issues
with clients in a culturally competent way.
Exploring other forms of information outside of academic research would also be beneficial
in trainings. At the moment, the very limited amount of research done on FSSWers does not
provide a comprehensive view of the needs of FSSWers. Additionally, most clinically-
relevant information that captures the voices of sex workers and describes their needs and
experiences is not captured within academic research products.
Current Resources—There are several nonprofits that focus on sex workers advocacy,
agency, and well being. Among them include St. James Infirmary and Sex Workers Outreach
Project (SWOP), The Sex Worker Project at Urban Justice Center, Helping Individual
Prostitutes Survive (HIPS), and Desiree Alliance. There are organizations that offer
community resources to connect sex workers as well as places to learn more about the sex
work community.
To summarize, it is critical to consider the individual, community, societal, and policy
factors that sex workers face when seeking treatment. As a community that faces
vulnerability to violence, stigmatization, and criminalization, access to culturally competent
mental health care is vital and a matter of public health.
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ACKNOWLEDGEMENT
The authors would like to thank Corrie Varga for assistance in manuscript preparation.
Preparation of this report was supported in part by a VA Rehabilitation Research and Development Career
Development Award – 2 (1IK2RX001492-01A1) granted to Heinz. The expressed views do not necessarily
represent those of the Department of Veterans Affairs.
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Weitzer R (2009). Sociology of sex work. Annual Review of Sociology, 35, 213–234.
Weitzer R (2012). Legalizing prostitution: From illicit vice to lawful business. NYU Press.
Williams DR, Neighbors HW, & Jackson JS (2003). Racial/ethnic discrimination and health: findings
from community studies. American journal of public health, 93(2), 200–208. [PubMed: 12554570]
Wilson HW, & Widom CS (2010). The role of youth problem behaviors in the path from child abuse
and neglect to prostitution: A prospective examination. Journal of Research on Adolescence,
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Wirtz AL, Peryshkina A, Mogilniy V, Beyrer C, & Decker MR (2015). Current and recent drug use
intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian
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Zheng T (Ed.). (2010). Sex trafficking, human rights, and social justice (pp.10). New York: Routledge.
Sawicki et al. Page 17
Sex Relation Ther. Author manuscript; available in PMC 2019 March 19.
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http://www.unaids.org/sites/default/files/media_asset/06_Sexworkers
https://swp.urbanjustice.org/sites/default/files/RevolvingDoorES
http://www.surgeongeneral.gov/library/mentalhealth/home.html
http://www.surgeongeneral.gov/library/mentalhealth/home.html
https://2001-2009.state.gov/r/pa/ei/rls/38790.htm
https://www.doi.gov/ocl/human-trafficking
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
https://www.dropbox.com/l/scl/AADvm7O3B9CLqg_y1OXE-xoxqMU2nQ2mKOw
-
Abstract
- Future directions for research and culturally competent clinical training for serving sex workers
Objectives
Unique Struggles of FSSW and Clinical Considerations
FSSW, Violence, and Trauma Exposure
Exposure to institutionalized violence and discrimination.
Unaddressed Mental Health Needs and Barriers to Care Engagement
Myths That Stigmatize FSSW
FSSW Should Be Criminalized
Legalization.
Decriminalization.
FSSW Cannot Be A Feminist Choice
FSSW: A Feminist Choice.
All FSSWers Are Equally Impacted By Stigma
All Sex Workers Experienced Childhood Trauma
FSSW Is Not Real Work
Future directions for research
Clinical Recommendations
Developing culturally competent trainings
Current Resources
References
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
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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
Copyright: © 2018 Platt et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
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
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https://doi.org/10.1371/journal.pmed.1002680
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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/
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
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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.
https://doi.org/10.1371/journal.pmed.1002680.t001
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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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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
Health impact of sex work legislation
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https://doi.org/10.1371/journal.pmed.1002680
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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Health impact of sex work legislation
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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)
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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.
https://doi.org/10.1371/journal.pmed.1002680.g002
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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)
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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)
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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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