writing and rhetoric, conditions and diagnosis in recreation,

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 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.doc 

Part 2.doc

__________________________________________________________________________________

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: 

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?

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

Abstract

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.
[email protected].

U.S. Department of Veterans Affairs
Public Access Author manuscript
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.

Objectives

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

Sawicki et al. Page 2

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clinical training agenda that can help optimize mental health care engagement and utilization

within the sex work community.

Unique Struggles of FSSW and Clinical Considerations

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

Sawicki et al. Page 3

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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.

Sawicki et al. Page 4

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Myths That Stigmatize FSSW

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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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
  • 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 and culturally competent clinical training for serving sex workers
    • 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

* [email protected]

Abstract

Background

Sex workers are at disproportionate risk of violence and sexual and emotional ill health,

harms that have been linked to the criminalisation of sex work. We synthesised evidence on

the extent to which sex work laws and policing practices affect sex workers’ safety, health,

and access to services, and the pathways through which these effects occur.

Methods and findings

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualita-

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

islation, police, and health. We operationalised categories of lawful and unlawful police

repression of sex workers or their clients, including criminal and administrative penalties.

We included quantitative studies that measured associations between policing and out-

comes of violence, health, and access to services, and qualitative studies that explored

related pathways. We conducted a meta-analysis to estimate the average effect of

experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and

condomless sex, among individuals exposed to repressive policing compared to those

unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically.

We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers

was associated with increased risk of sexual/physical violence from clients or other parties

(odds ratio [OR] 2.99, 95% CI 1.96–4.57), HIV/STI (OR 1.87, 95% CI 1.60–2.19), and con-

domless sex (OR 1.42, 95% CI 1.03–1.94). The qualitative synthesis identified diverse

forms of police violence and abuses of power, including arbitrary arrest, bribery and extor-

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

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

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

a1111111111

a1111111111

a1111111111

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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

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.

• Meta-analyses suggest that on average repressive policing practices of sex workers were

associated with increased risk of sexual/physical violence from clients or other partners

across 9 studies and 5,204 participants.

• Sex workers who had been exposed to repressive policing practices were on average at

increased risk of infection with HIV/STI compared to those who had not, across 12,506

participants from 11 studies. Repressive policing of sex workers was associated with

increased risk of condomless sex across 9,447 participants from 4 studies.

• The qualitative synthesis showed that in contexts of any criminalisation, repressive

policing of sex workers, their clients, and/or sex work venues disrupted sex workers’

work environments, support networks, safety and risk reduction strategies, and access

to health services and justice. It demonstrated how policing within all criminalisation

and regulation frameworks exacerbated existing marginalisation, and how sex workers’

relationships with police, access to justice, and negotiating powers with clients have

improved in decriminalised contexts.

What do these findings mean?

• The quantitative evidence clearly shows the association between repressive policing

within frameworks of full or partial sex work criminalisation—including the criminali-

sation of clients and the organisation of sex work—and adverse health outcomes.

• Qualitative evidence demonstrates how repressive policing of sex workers, their clients,

and/or sex work venues deprioritises sex workers’ safety, health, and rights and hinders

access to due process of law. The removal of criminal and administrative sanctions for

sex work is needed to improve sex workers’ health and access to services and justice.

• More research is needed in order to document how criminalisation and decriminalisa-

tion interact with other structural factors, policies, and realities (e.g., poverty, housing,

drugs, and immigration) in different contexts, to inform appropriate interventions and

advocacy alongside legal reform.

Introduction

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

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

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

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

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

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

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

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

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

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

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

bia, and homophobia [17].

Health impact of sex work legislation

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

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

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 4 / 54

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

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 5 / 54

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

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 6 / 54

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

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 7 / 54

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

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 8 / 54

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

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

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

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

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

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

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

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

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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PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 17 / 54

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

Health impact of sex work legislation

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 18 / 54

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

Health impact of sex work legislation

PLOS Medicine | https://doi.org/10.1371/journal.pmed.1002680 December 11, 2018 19 / 54

(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

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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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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].

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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

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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]

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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]

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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

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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]

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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

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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

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

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

Data curation: Lucy Platt, Pippa Grenfell, Rebecca Meiksin, Jocelyn Elmes.

Formal analysis: Lucy Platt, Pippa Grenfell, Rebecca Meiksin, Jocelyn Elmes.

Funding acquisition: Lucy Platt.

Methodology: Lucy Platt, Pippa Grenfell, Rebecca Meiksin, Susan G. Sherman, Teela Sanders,

Peninah Mwangi, Anna-Louise Crago.

Supervision: Lucy Platt.

Writing – original draft: Lucy Platt.

Writing – review & editing: Pippa Grenfell, Rebecca Meiksin, Jocelyn Elmes, Susan G. Sher-

man, Teela Sanders, Peninah Mwangi, Anna-Louise Crago.

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