Sex workers to pay the price
Authors: Petra Boynton, Linda Cusick
Journal: BMJ (2006)

In 2004 the UK Home Office published a consultation paper on sex work, after a review of the Sex Offences Act (2003). The paper, Paying the Price,1 was criticised by specialist services for giving less priority to the health of sex workers than before and for focusing too much on issues of criminal justice, and by health researchers for its unethical use of questionnaires and interviews. The resulting Home Office strategy2 published last week aims to challenge the view that street prostitution is inevitable; achieve an overall reduction in street prostitution; improve the safety and quality of life of communities affected by prostitution, including those directly involved in street sex markets; and reduce all forms of commercial sexual exploitation.

The strategy looks to the controversial Swedish model that criminalises men who pay for sex, and uses police photographs of sex acts and possession of condoms as evidence of sex work. This discourages sex workers from using condoms and introduces tension and potentially violence between them and clients. The Home Office proposes a range of approaches for a variety of sex markets, based on the sex of workers and the locations where sex workers and clients meet. But the strategy does not explicitly tackle health and human rights and will not, therefore, tackle genuine areas of vulnerability and exploitation. Currently, children are sexually abused, people are trafficked and enslaved, and vulnerable individuals, including those with drug dependency or mental health conditions, are coerced and controlled, often by organised criminal gangs. Neither adult sex workers nor clients dare to report these abuses for fear of exposing their own involvement in sex work.

The proposed strategy rejects calls to license premises which comply with ordinary requirements of workplace legislation on health, safety, and labour. A licensing system could ensure that children were not employed, employees were not in possession of drugs, and foreign nationals had work permits.

Instead the strategy focuses on disrupting street sex markets. Kerb crawling will be policed in established red light areas despite strong evidence that this will simply displace sex work to other locations and increase the prevalence of acquisitive crime.3 This will also reduce sex workers' negotiating powers, make it harder for them to find clients, increase their time on the streets, and force them to solicit more directly— increasing the risk of causing offence or distress to people not looking for paid sex. These conditions are directly linked to increased violence, pressure to abandon safer sex practices, and increased public disorder, including vigilante attacks.4

Sex workers are now uncertain about their legal status and are unsure whether the new Home Office strategy has become law. Outreach services and health researchers have noted increased fears among sex workers regarding the safety and confidentiality of such services.

Specialist healthcare services in red light areas face an uncertain future. Outreach work, provision of condoms, needle exchange schemes, and primary care for a population rarely registered with a general practitioner could be compromised if the strategy is enforced and sex workers become reluctant to seek help. Without access to specialist fast track services for sexual health, sex workers may face delays in receiving treatment for sexually transmitted infections, which could have profound consequences both for sex workers and the wider population.

The recent increase in sexually transmitted infections in the general population in the United Kingdom contrasts with a reduced prevalence in female sex workers.5 And the prevalence of HIV infection in sex workers, mainly associated with injecting drug use, remains low— between 0% and 3.5%.5 Sex workers have a responsible approach to managing the risk of sexually transmitted infections, with a high prevalence of condom use for commercial vaginal sex (98%). The Home Office strategy shows inadequate understanding of risk, and the proposed changes could increase negative health outcomes, while limiting patients' access.

Multiagency work by healthcare professionals, police, social services, and sex workers will be disrupted if red light areas are phased out as the strategists intend. This will increase the risks to sex workers, 87 of whom have been murdered in the United Kingdom since 1990.6 Collaborative working gives sex workers the support to report violent clients and other predators who aim to coerce and control them. The lack of detail in the strategy about implementing the new approaches, especially regarding indoor sex work, leaves most of the sex workers we have spoken to feeling uneasy that they will have to wait and see how the strategy affects their access to health care and their contact with the criminal justice system.