Title: A participatory mixed-method evaluation on how removing enforcement could affect sex workers' safety, health and access to services, in East London
Funder: Department of Health and Social Care

Abstract: Sex workers are at disproportionate risk of violence, sexual and emotional ill-health harms that are linked to sex work criminalisation. In the UK, indoor female sex workers are 2.6 times more likely to experience recent client violence if they have ever been arrested/in prison, irrespective of work location, migrant status and drug use. Internationally, sex workers with experience of police enforcement are up to 4-5 times more likely to acquire HIV/STI, accept more money for, be pressured into or engage in unprotected sex with clients. Criminalisation, including of sex workers’ clients, exacerbates these health risks by: disrupting access to care, work environments and safety strategies; disproportionately targeting street-based, ethnic minority and transgender sex workers; and reinforcing structural vulnerabilities (e.g. insecure housing). Emerging international data indicate that decriminalisation can significantly improve safety, care access, physical and emotional health. We will evaluate the impact of removing police enforcement sanctions on female, male and transgender sex workers’ health (violence, HIV, STIs, emotional ill-health) and access to health/social care – a question that has not been researched in the UK and to a limited extent elsewhere. Rather than traditional experimental designs, which require randomisation of an intervention and appropriate comparison areas [19], and which do not account for context [18] and complexity, we will use an innovative, theory-driven evaluation design. [21] We will: estimate the impact of removing sanctions on our outcomes, via mathematical modelling (C); measure the effects of varied enforcement on outcomes via longitudinal, linked behavioural/biological survey data (B), to parameterise the model (C) and capture changes over time (e.g. reduced enforcement due to the presence of Open Doors); investigate how enforcement shapes these outcomes, using qualitative methods (A), to develop indicators and a ‘theory of change’ to guide the evaluation (B/C); and identify contextual factors that influence acceptability, feasibility and implementation of non-enforcement, to inform any scale-up (A). Routine enforcement data across study boroughs (D) will be triangulated with (A/B) to refine measures of (non)enforcement and corroborate changes in policing over time. We will collaborate with sex workers on study design, conduct and dissemination. The findings will inform advocacy for evidence-based policy and any scale up of non-enforcement, in the UK and internationally, as a structural intervention to improve sex workers’ health, safety and well-being.

Lay abstract: Sex workers are more likely to experience violence, HIV and sexually transmitted infections (STIs) than the rest of the population, and some have high rates of anxiety, depression and drug use. International research shows that sex workers who have experienced police enforcement (e.g. arrest, displacement) are more vulnerable to these health problems those who have not. This can happen by disrupting sex workers access to health services, their work environments and their safety strategies: for example, sex workers may move to isolated, dangerous places to avoid arrest, and where outreach services are less likely to reach them, or they may work alone to avoid being prosecuted for running a brothel. Evidence from Sweden shows that criminalising sex workers’ clients has similar effects. We also know that street-based, ethnic minority and transgender sex workers are most likely to be targeted by police, and that criminalisation reinforces homelessness and poverty - a police record, for example, can make it very difficult to access housing. This shows how criminalisation of sex work contributes to the health inequalities that sex workers experience. Where sex work has been decriminalised (e.g. New Zealand) research tells us that this approach can significantly improve sex workers’ safety, access to health care and physical and mental health. There is no such evidence for the UK, where most aspects of sex work are criminalised (e.g. soliciting, kerb crawling, working with others). There is now an opportunity to evaluate an alternative approach in Hackney, East London, where instead of arresting sex workers/clients, local police refer sex workers to a support service to address their health and social care needs. This compares with neighbouring Newham and Tower Hamlets where the support service is newer and police continue to arrest sex workers and clients. This research will evaluate the effects of removing police sanctions on sex workers’ health (violence, HIV, STIs, emotional health (e.g. anxiety)) and access to health/social care, in East London. We cannot use standard experimental approaches because we are not able to ‘randomise’ the intervention (non-enforcement) and there is a lack of appropriate comparison areas. Instead, we will use an innovative evaluation design that involves multiple methods and approaches and that also takes into account the role of ‘context’. Using the diversity in policing across East London, we will assess how different levels of enforcement affect sex workers’ health (‘natural experiment’) and how this changes over time (e.g. if enforcement reduces because of the sex worker support service) – via a baseline and follow-up survey. We will use the results to estimate how removing enforcement across all study boroughs could affect sex workers’ health, through mathematical modelling. We will complement this with qualitative interviews and observations to find out how (not) being exposed to enforcement affects sex workers’ health and risks. This will help us to design the survey and the mathematical model, and to find out how acceptable and feasible non-enforcement is locally, and how it is put into practice. We will involve sex workers as researchers and advisory group members, to ensure they have a say in the research and how it is used. Together we will use the findings to advocate for evidence-based policy and practice to improve the health, safety and well-being of sex workers in the UK and internationally. More information about the project can be found at http://eastlondonproject.lshtm.ac.uk/

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: INFECTION;INJURIES AND ACCIDENTS;MENTAL HEALTH