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Hyunsoo Chung

Meghan Hynes, MPH

Sex workers face a myriad of intersecting health and safety concerns including HIV transmission, access to health and social services, violence via clients, police harassment, social stigma and economic insecurity. A growing demand for the universal decriminalization of sex work has garnered significant media attention and has brought about heavy public scrutiny. The countries of South Africa, Sweden and New Zealand all employ different legal approaches to the sex trade, subscribing to prohibition, partial decriminalization and legalization, respectively. The impact of the three legislative models on the health and wellbeing of sex workers vary accordingly. This article considers South Africa, Sweden and New Zealand as proxies of the three legal paradigms, assesses the varying outcomes on the lives of female sex workers, and concludes that the overwhelming body of evidence points to a positive association between decriminalization and improved health and working conditions for sex workers. This article appraises the impacts of the various systems, analyzes pervasive themes and provides a brief assessment of innovative approaches used to address social stigma and health disparities.

Introduction

The prospective decriminalization of the sex trade has inspired some of the most divisive arguments in global health policy for decades. Recent calls for the end of prohibition of sex work by Amnesty International and other health and human rights organizations have garnered significant media attention and catalyzed a global debate.1 This highly publicized policy initiative suggests a shifting mentality in the public opinion of sex work from a largely prohibitive stance toward an approach which seeks to advance public health. The prohibition of sex work, which has traditionally rested in ideology rather than evidence-driven policy, is a trend that has become increasingly anachronous in recent years.2 Appeals to abolish the systems that criminalize sex work are gaining legitimacy in the public’s consciousness and with stakeholders such as sex workers, advocates and legislators all over the world.

While some administrations prohibit sex work on grounds of cultural or religious opposition, others do so in an attempt to protect public health, limit disease transmission and deter the exploitation of women and other marginalized populations. Some countries, such as Sweden, penalize consumers of sex in efforts to empower women and promote gender equality. Proponents of decriminalization, however, argue that regulation, as opposed to prohibition, helps to promote the visibility of this traditionally clandestine practice and allows for more effective public health interventions. Yet despite recommendations from multinational organizations, such as The Joint United Nations Programme on HIV and AIDS (UNAIDS) and Amnesty International, many administrations remain staunchly opposed to legalization.3

Background

Legal approaches to sex work fall into one of three categories: full prohibition, partial decriminalization and legalization. South Africa, Sweden and New Zealand represent each of the three categories, respectively, and the impacts of these policies on the health and wellbeing of sex workers vary accordingly.

Discussions of the partial or total decriminalization of sex work have been ongoing in South Africa’s parliament and media for several decades, but despite the vocal outcries of select politicians and global health entities, full prohibition of the sex trade remains intact.4 In Sweden, clients can face fines and potential imprisonment for their role in sex-based transactions, while sex workers are legally permitted to provide services.5 At the other end of the spectrum, New Zealand has legalized the sex trade and seeks to improve public health with regulation. This policy analysis will juxtapose the impacts of the policies on the health and working conditions of Female Sex Workers (FSW) in the three aforementioned countries in order to compare their outcomes and to advocate for the adoption of evidence-based policy that advances both public health and human rights.

The World Health Organization (WHO) defines sex workers as “Women, men and transgendered people who receive money or goods in exchange for sexual services, and who consciously define those activities as income generating even if they do not consider sex work as their occupation.”6 According to the Center for Disease Control (CDC), this may include escorts, exotic dancers, workers with legal recognition, people who work in massage parlors, people who work in the adult film industry as well as men, women and transgender people who participate in survival sex or street-based sex work.7 The catalysts for engaging in the sex industry vary drastically between different individuals and populations. Due to the breadth of these circumstances, this analysis will focus primarily on cisgendered women who are street-based, who work privately out of residences or on the Internet, or who work in brothels or other similar establishments. However, the experience of cisgendered female sex workers cannot be assumed to translate directly to other vulnerable populations that are outside of the scope of this analysis. There is a need for greater research of the political implications for transgender and male sex workers, who often experience stigma, health disparities and violence to a higher degree than cisgendered women. Additionally, the field of sex work is exceedingly complex. This policy analysis seeks to provide an objective comparison of the body of evidence regarding sex work. However, as with any similarly charged subject, the pre-existing views of the author cannot be entirely extirpated from analysis.

South Africa

Background

South Africa’s Sexual Offenses Act, 1957 penalizes “any person who knowingly lives wholly or in part on the earnings of prostitution.”8 While these infractions are punishable by fines or imprisonment, sex work is nonetheless relatively common in South Africa.9 With an unemployment rate of over 25% and an annual per capita GDP of $6800, many women turn to alternative markets to generate income.10 In 2013, the South African National AIDS Council (SANAC) estimated that between 0.7% to 4.3% of the adult female population had participated in transactional sex.11

The legal status of sex work in South Africa has been periodically called into question by the public and by legislators. The drafting of the constitution during the early post-apartheid period inspired critical discourse amongst legislators regarding the criminalization of the sex trade.4 In 1997, the Gauteng Department of Safety and Security established a taskforce which incorporated both sex workers and non-governmental organizations (NGOs) that focused on the potential benefits of decriminalizing the sex trade. This campaign was eventually adopted as a part of the 1998 ANC platform.12 After the election, however, the issue was abandoned in the face of public opposition. The discussion was largely absent from civil discourse until 2010, when the National Commissioner of Police publicly advocated an injunction on the prosecution of sex workers in red light districts during the World Cup events.13 While inspired by an effort to protect the health of sex workers and South African citizens amidst an anticipated influx of sex tourism, this injunction was ultimately denied amidst fears that it would incite human trafficking. Due to an increased police presence throughout the event, FSW noted an 11% increase in interactions with law enforcement during the World Cup and a 5% decrease in engagement with health services in Cape Town, Johannesburg and Rustenburg.14

Prohibition and Health in South Africa

Testimonials from 136 FSW in the southern African region reveal that the lack of legal recognition of the sex trade fosters a perceived sense of enmity from the state.12 Women report that the fear of prosecution and maltreatment prevent them from engaging in healthcare and preventative services. Sex workers in South Africa frequently avoid healthcare facilities where they experience a lack of privacy and may be denied services.15 Women who have disclosed their involvement in the sex trade to healthcare providers report having been denied Post Exposure Prophylaxis (PEP), substance use treatment, emergency contraception and condoms.15 Barriers to accessing health services for FSW have significant implications for the transmission of HIV within this community. While the HIV prevalence rate is estimated to be 19.1% in the general South African population, it is thought to be between 44% and 69% in sex workers.15 20% of all new HIV infections in South Africa are estimated to be related to sex work.11

Medical advances made in HIV prevention are also hindered by the prohibition of sex work. The Treatment as Prevention method, established as an effective tool in preventing the spread of HIV since 2011, utilizes antiretroviral treatment (ART) to suppress HIV viral loads in those living with the virus. This method has proven to be extremely effective in preventing transmission, lowering the risk by as much as 96 percent in clinical trials.16 However, the current reluctance or inability of sex workers to access preventative services restricts the epidemiological benefits of treating HIV as a preventative measure. Although HIV prevalence is significantly higher in FSW than the general population, this group is 12 times less likely to be on ART than other South Africans.17

The health and wellbeing of FSW in South Africa are not merely products of the legal system; researchers have found that social stigma and discrimination are also responsible for declining health conditions of FSW. A 2012 study of HIV prevalence found that much of the increased risk for FSW is a “manifestation of their extraordinary social and economic vulnerability and the high levels of stigma and violence attached to sex work.”18 Contempt for sex workers is prevalent in South Africa’s political and social systems and prevents many women from receiving basic health services. FSW have reported being treated with malice from healthcare workers who suspect them of participating in sex work and can be subjected to inadequate treatment or denied treatment altogether.15

The severity of these trends has not been entirely overlooked by domestic health entities. In 2013, the South African National AIDS Council released an official strategy entitled The National Strategic Plan for HIV Prevention, Care and Treatment for Sex Workers. This strategy, developed with input from sex workers and advocacy groups, establishes an agenda for addressing the HIV epidemic among sex workers that includes increased dissemination of prevention materials, information and education, increased coverage of sex worker and client services, mobilization of sex worker advocacy groups and formal acknowledgements of the impact of stigma on the population.11

Prohibition and Working Conditions in South Africa

The lack of legal recognition for sex workers precludes the securement of occupational rights, and reinforces stigma against this population. FSW are viewed by the state as “reservoirs of disease” and are vilified as the source of the HIV epidemic in the country.12 In a survey of street-based sex workers in Cape Town, FSW were asked how often they felt afraid for their safety. 28% of women reported “never,” 41% replied “sometimes,” 19% said “often” and 12% said “always.”19

Police in South Africa are often the most severe perpetrators of violence toward sex workers. In 2008, the Institute for Security Studies partnered with the Sex Worker Education and Advocacy Taskforce (SWEAT) to conduct 164 interviews with sex workers. The researchers found that 47% of respondents had been threatened with violence by police, 12% had been raped by police and 28% had been blackmailed for sex by police.19 Fifty-three percent of FSW polled stated that they always carried condoms and believed condoms to be essential in preventing the transmission of HIV.20 However, many women reported a reluctance to carrying condoms as they are frequently confiscated by police or are used as a means of unlawful detention. One South African outreach worker stated: “[The police officer] said we are not allowed to give sex workers condoms because we influence them to do sex work and it is not allowed.”20 Additionally, formal documents issued by the National Prosecuting Authority in 2011 encourage police to make arrests based on the clothing a woman wears, the streets she frequents and whether or not she is a “known prostitute”.20 The maltreatment perpetrated by police in South Africa creates an environment in which women are afraid of law enforcement. The futility of reporting abuse and the fear of the police are widely shared sentiments that prevent women from interacting with police in any matter. In contrast to the legalization and regulation of the sex trade, which allows for women to freely access health services and to leverage their rights against harassment, this model puts sex workers at odds with the state and increases the risks of the trade.

Sweden

Background

The Prohibition of Purchase of Sexual Services Act, 1999 prohibits the purchase but permits the sale of sex.21 The legislation is founded on the notion that women who are involved in the sex trade are inherently victims of male exploitation.21 The authors of the law saw this measure as a step toward achieving gender equality. This model, also known as the “Nordic Model,” has received widespread acclaim throughout Europe. The European Parliament endorsed this model in 2014; it has already been replicated in Norway and Iceland and is under consideration in many other countries in European Union.22

Kasja Wahlberg, Sweden’s National Rapporteur on Trafficking in Human Beings, helped to introduce the legislation in 1999. In 2013, Wahlberg praised the law saying, “We have a small group of pro-prostitution lobbyists that are very powerful. The Sex Purchase Act was not passed for them; it was passed for the majority of women who suffer from prostitution. If women want to be in prostitution and don’t want any help, we don’t interfere.”23 However, many sex workers take issue with Wahlberg’s claim, and have raised concerns about the absence of stakeholders in the drafting of the legislation. The World AIDS Commission states, “The 1999 law that criminalized clients was passed without any consultation with sex workers. When sex workers tried to raise their concerns, they were ignored, and accused of either being non-representative or of having a ‘false consciousness’…This ignores and belittles the real experiences of sex workers.”9 Many FSW and scholars have since publicly denounced the legislation as paternalistic rather than representative of their needs.9

The Swedish Census states that between 1998 and 2003 there was a 32% decline in the number of street based sex-workers in Stockholm, 65% in Gothenburg and 41% in Malmö.24 In 2010, the Swedish Government published an evaluation of the act known as The Skarhed Report. The report is overwhelmingly favorable of the law, and cites its success in diminishing the presence of sex work in the country. Since the law was enacted, researchers agree that the number of street-based workers has declined.9 The Skarhed report also states that the number of men who reported ever having purchased sexual services had decreased since 1999. However, the Swedish Institute, which published the report, acknowledge the dearth of empirical evidence on which to base their findings: “We realized that it would not be possible in the framework of this inquiry to produce the precise knowledge about prostitution that politicians and debaters request, but which no authorities or researchers have been able to generate in the nearly eleven years that the ban against the purchase of sexual services has been in place.”25 This lack of empirical evidence used to support the claims of the report raises concerns about the legitimacy of its findings.

Additionally, critics take issue with the formation of the report and claim that its premise is biased, as its authors explicitly state, “One starting point of our work has

been that the purchase of sexual services is to remain criminalized.”26 In addition to the Skarhed Report, an external report commissioned by the Swedish Association for Sexuality Education (RFSU) and Malmö University found that the Act’s benefits are “greatly exaggerated.” 27 Kristina Ljungros, who chairs the RFSU, states, “The law has not had the intended effect, and has increased uncertainty for sex workers.”27 The instability of client-flow destabilizes the market and creates new risks for women in the industry.

Critics argue that the decreased visibility of sex workers correlates with deteriorating conditions for FSW, while experts discredit the notion that the market for sex has diminished due to the legislation and assert that this trend was in progress prior to the enactment of the law.28 Estimates of the number of women working in the industry before and after the legislation was enacted are highly variable. Michelle Goldberg of the Pulitzer Center on Crisis Reporting states, “No one knows precisely how the law has affected the number of prostitutes in Sweden, in part because its passage coincided with the coming of the Internet, which changed the way the market works.”28 Most researchers agree that in addition to the legislation, the use of cell phones and the Internet have contributed to the shift from street-based workers to workers based in more clandestine environments.

Partial Prohibition and Health in Sweden

Both supporters and opponents of the legislation acknowledge the difficulty of evaluating the impacts of the law on sex workers due in large part to the diminished presence of street-based workers. There are no reliable estimates of new HIV or Sexually Transmitted Infections (STIs) among sex workers since 1999. The lack of empirical data prevents a meaningful appraisal of the epidemiological impacts of the legislation. However, testimonies from FSW, healthcare providers and social service workers suggest that there have been several unintended impacts on the health of sex workers.29 Reports by the Global Network of Sex Work Projects (NSWP) note an increased difficulty in promoting safer sex as the provision of condoms is now seen as a tacit endorsement of an illegal act. According to the NSWP, “Condoms are not seen as measures to promote health and to reduce harm, but instead as means with which to attract sex workers to the Stockholm Unit’s offices (where condoms are available).”29 These facilities are staffed by officers who are intended to divert women from the sex trade and many FSW avoid these centers out of a fear of judgment and to avoid agents of law enforcement. Additionally, street-level outreach to sex workers is non-existent, and access to condoms has been further diminished as they are withheld from FSW. The NSWP states that although The Swedish National Board of Health and Welfare explicitly targets sex workers and their clients for HIV and STI prevention, the breadth of their efforts is precluded by the Prostitution Units who oppose providing condoms to sex workers during outreach.29

The political structure of Sweden permits its municipalities and counties considerable power in policy implementation, specifically surrounding matters related to healthcare.30 The interpretation of the Ban on The Purchase of Sexual Services has varied across the country. While Stockholm has been stringent with the interpretation of the law, and views the provision of harm reduction materials as aiding in an illegal act, Malmö’s Prostitution Unit has embraced aspects of harm reduction.29 The NSWP reports that Malmö Prostitution Unit actively distributes condoms to sex workers and their clients. The Unit also provides a “Harm Reduction Pack” which was written with input from sex workers and contains a guide to safer sex work. However, Malmo’s efforts at reducing harm for sex workers have not been endorsed by the Swedish government and The National Coordinator Against Trafficking and Prostitution has stated that Malmö’s policies encourage women who are not already involved in the trade to become sex workers.29

Social workers have commented on their diminished ability to track and assist FSW since the act took place, and many have voiced frustration that funds which would otherwise be used for outreach have instead been diverted to prosecution.31 Providers have been outspoken about the deteriorating conditions for women who remain on the streets and assert that FSW who wish to engage in social services are expected to denounce their profession and to accept the victim narrative. If they fail to do so, they are said to have “mental health issues” and may be denied services.29 There have also been instances in which Prostitution Unit Social Workers have refused to treat or provide referrals to sex workers until they have ceased working in the industry for a set period of time.29 Testimonies from healthcare workers corroborate this finding. One Stockholm-based healthcare provider states, “The day when they don’t like [prostitution] anymore, they can come to me. So I don’t spend my energy on this group of people.”29

Partial Prohibition and Working Conditions in Sweden

There are conflicting views on the impacts that the 1999 Act has had on working conditions for FSW. Pros-Centre, an organization that seeks to assist women exiting the sex trade, credits the law as creating an effective impetus for women to leave the industry. The group states that between 1999 and 2001, 60% of the 130 clients they reached had reportedly left the sex trade permanently.31 However, the extent of the organization’s follow-up with these women is unclear.

Many FSW denounce the Act and believe that it has brought about increased risks. FSW report that men are afraid to approach them on the street, and now prefer the anonymity of the internet. With less demand for their services, street-based workers must compete with one another for business. Women are less capable of determining whether or not clients could potentially be dangerous.29 The NSWP states, “Services that they may not have provided previously may now have to be provided in order to make enough money; sex workers are additionally less able to reject clients they would have rejected before, and sex workers are not able to charge the same amount for their work.”29 The ability to appraise the safety of a client or transaction has led to a subsequent uptick in violence towards workers.9

Furthermore, relations between FSW and the police have deteriorated since the 1999 law went into effect. Women report having been videotaped having sex with clients in their cars in order for the police to collect evidence and report being strip-searched for condoms by officers.9 The increased surveillance of the sex trade has also impacted living conditions for sex workers. Anti-brothel laws target property owners, who may be charged with pimping if sex workers are found to be operating within their establishment. The International Union of Sex Workers reports that the legislation has incited significant abuse via police including “being harassed at home, being made homeless due to police threats to prosecute their landlords as living off proceeds of prostitution, being told by police that sex workers cannot be raped and being gang-raped by a group of police officers.”32 Fearing eviction, homelessness and police harassment, women struggle to keep their identities hidden and are less likely to report abuse.9

Furthermore, sex workers have stated that in addition to their compromised ability to negotiate safer sex and their ability to receive health services, they also face discrimination when attempting to access social services.9 A paradoxical stipulation of the Swedish tax system mandates that sex workers pay income taxes; however, sex work is not legally considered a profession or a business: “The government forces [sex workers] to break the law: they must either lie, register a business in another category, or not pay taxes. If they do not register, they cannot participate in the social security benefits that are available to other workers.”26 The National Board of Health and Welfare found that half of the FSW who had been polled believed that the Act prohibits women from seeking the assistance of social services despite having paid into them.29

The Swedish policy prohibits non-citizens from engaging in sex work. Immigrant women are subject to immediate deportation if found to be participating in the sale of sex. However, a substantial portion of FSW on the streets of Sweden emigrated from elsewhere in Europe.26 This policy has made sex workers living in Sweden more vulnerable to abuse and pushes them further away from preventative services for fear of deportation. Don Kulick, Professor of Anthropology at Uppsala University in Sweden, recounts, “I don’t think for example that a Russian woman would dare to report a man for violence against her, because then she would risk not being given a visa if she ever wanted to come back to Sweden, because it would have become known that she is a prostitute.”33 The government has recently slackened this policy for EU citizens, but women from other regions are still unprotected.34

The authors of the Act had intended for the ban on the sale of sex to deter human trafficking. In 2010, The Swedish Government reported that police believed that it “is clear that the ban on the purchase of sexual services acts as a barrier to human traffickers and procurers who are considering establishing themselves in Sweden.”25

However, the National Criminal Investigation Unit estimates that between 400 and 600 foreign women participate in Sweden’s sex trade every year, and concludes that there is no evidence that the number of people entering the sex trade involuntarily has decreased since the implementation of the ban.31

New Zealand

Background

In 2003, New Zealand awarded full legal recognition to all sex workers under the Prostitution Reform Act (PRA). Prior to 2003, the sale of sex was not explicitly illegal; however, many ancillary activities surrounding sex work, such as operating a brothel, were prohibited.35 A coalition known as The New Zealand Prostitutes Collective (NZPC) helped to catalyze the formation of the PRA. Active since 1987, this group worked in conjunction with many stakeholders and partner organizations such as The New Zealand Federation of Business and Professional Women and the Young Women’s Christian Association (YWCA) to inform and promote the legislation.35

The PRA underwent multiple iterations from the time it was first introduced in 1994 to when it was adopted in 2003. When drafting the law, legislators consulted with the New Zealand AIDS Foundation (NZAF), public health and sexual health groups, minority and indigenous groups and other invested parties. The NZAF worked in tandem with policy-makers to create a final framework that would support sex workers. The act also set up a Prostitution Law Review Committee (PLRC), which was tasked with conducting a rigorous monitoring and evaluation process to assess the impacts of the policy. This committee was designed to be representative of the industry; three out of its eleven members must be nominated by the NZAF.35

Legalization and Health in New Zealand

In 2007, the University of Otego conducted an impact evaluation on behalf of the Prostitution Law Review Committee. This multi-methods study, entitled The Impact of the Prostitution Reform Act on the Health and Safety Practices of Sex Workers, included quantitative and qualitative data from Auckland, Christchurch, Wellington, Nelson and Napier. A similar study conducted in Christchurch in 1999 serves as baseline for comparison with the 2007 evaluation.

The PRA asserts that sex workers, their clients and auxiliary workers such as brothel managers must take all reasonable means to make sure that a protective barrier is in place during any act of penetration or any other sexual activity that may pose transmission of disease. The 2007 impact analysis found that 80% of female respondents reported always using protection for vaginal, anal and oral sex with clients, and around 90% of respondents had used a condom during every sexual encounter within the past month.35

Women who tended to work on the street were more likely to report not using condoms than women who worked in brothels or under management. The majority of women reported that they had turned away a client that they did not want to service in both 1999 and 2007. Managed workers, as opposed to private and street-based workers, were the only group which saw a statistically significant change in their ability to decline transactions; from 47% in 1999 to 68% in 2006 (p=0.0009).35 More than 50% of the respondents reported having discontinued transactions when a client refused to wear a condom.35

FSW in New Zealand have a significantly higher rate of engagement in the healthcare system than sex workers in New Zealand and Sweden. The 2007 impact report found that 87% of survey respondents had a regular doctor, adding “few survey participants report non-attendance at sexual health check-ups, with most going to their own doctor, a sexual health centre, or NZPC [drop-in center].”35 While only 3.7% of sex workers surveyed said that they had not seen a healthcare provider for a sexual health check-up, many women in the study revealed that they frequently do not disclose their profession to health care workers. Half of those who reported seeing a doctor regularly did not tell their physicians that they had participated in sex work due to fear that stigma would impact the quality of their care.35 There were no marked changes in this figure since the baseline study. These findings indicate that despite the legal status of the trade, social stigma continues to inhibit access to care.

Legalization and Working Conditions in New Zealand

Under the PRA, sex workers are awarded the same rights as other workers, including the ability to sue for sexual harassment from managers, challenge unsafe practices and join unions. Owners of brothels are required to pass health inspections, obtain government certifications, display NZPC materials and inform workers of their rights. However, while most women report that the PRA has had a positive impact on their health and safety, some workers report confusion about their rights; still others have expressed that public displays of NZPC material have been bad for business.35 Women who work in managed facilities have had mixed encounters with the implementation of their rights in the workplace. In qualitative interviews, one worker recalls, “They had nothing on STDs anywhere. They had no information about NZPC. They sold all their girls the condoms…None of the girls even knew that there was NZPC.”35 Despite the potential discrepancies in implementation, over 90% of workers in the 2007 evaluation stated that they felt that their rights had improved under the PRA.35

The outcomes evaluation also reports reductions in violence toward sex workers. FSW reported sharing information on “bad clients” amongst each other and receiving alerts from brothel management, the NZPC, physicians, nurses and counselors regarding dangerous clients.35 Many women cited the “Ugly Mugs” book kept by some NZPC branches as a way to recognize dangerous clients.35 This free flow of information allows sex workers to better avoid potentially dangerous interactions. The diminished threat of violence has had significant implications for this population; before legalization in 2003, 37% of sex workers felt that they had the ability to refuse to see a client. By 2007 that statistic had nearly doubled to 62%.35

One concern raised by Parliament members was the potential for increased human trafficking as a result of the liberalization of sex work policy. However, a formal committee organized by the University of Victoria determined that there is no connection between trafficking and the legal status of the sex industry and that the PRA has not caused an increase in the number of underage girls in the sex industry36 Since 2003, however, sex workers have reported a marked difference in their relations with the police. Over half of participants in the impact assessment stated that there had been a positive change in their relations with police since the PRA.35 But while gains have been made between police and sex workers, this relationship remains flawed. The impact evaluation found that most acts of violence, theft and professional maltreatment still go unreported to police.

Despite advances in healthcare and occupational rights, about 10% of women in the 2007 assessment reported having been physically assaulted by a client in the past year, 3% reported rape and 8.3% reported having money stolen by a client.35 While violence toward FSW has not been eradicated with the legislation, the majority of workers stated that they felt as if the risk of violence has decreased.35

Discussion

Overview

Stigma, violence, police harassment, the lack of bargaining power and misinformation regarding the routes of HIV and STI transmission are significant impediments to health of South African sex workers. These factors intersect with and contribute to other health and social concerns of FSW, namely their ability to exercise control over working conditions. The illegal nature of sex work in South Africa impedes the ability of FSW to engage in formal health care services. When faced with these conditions, women avoid healthcare providers in order to protect themselves from persecution, placing them at a much higher risk of contracting HIV.

Likewise, the system of partial prohibition in Sweden has shown to be largely ineffective, if not detrimental, to sex workers. The implementation of the 1999 law, purportedly enacted on behalf of this population, has led to declining visibility and access to healthcare services. Due to the reported drop in the demand for services from street-based workers, their willingness to turn clients away has been constrained. Instead of lowering risk of harm via clients, this legislation creates a race to the bottom for prices and leaves women with less agency to negotiate safer sex. Women are forced to take more clients to maintain their income level and are unable to afford to advocate for their own needs when it comes to safety and health. And although the Swedish law does not criminalize FSW, it neglects to address the social stigma that they endure. The assertion that all sex workers are victims contributes to a sense of shame and stigma and makes women less likely to seek out services or to engage in candid conversations with health providers.

In contrast, the rigorous monitoring and evaluation process conducted in New Zealand reveals that legalization has decreased the risk of violence toward FSW, improved relations with police and lowered risks of disease transmission. The securement of occupational rights is a significant gain for the industry, as they necessitate safer working conditions and provide legal avenues for recourse. In contrast to Sweden, where FSW report a perceived inability to decline unprotected sex due to threats of violence or threats to their livelihood, women in New Zealand have comparatively more sovereignty and state support. In addition to providing tangible benefits, these rights are also affirming to sex workers and can help to ease anxieties and stress that often spur other health issues.37 Women are better able to advocate for their health and safety knowing that they have the endorsement of the state.

Commonalities

Disparities in health infrastructure and conditions, political climate and culture in the three nations limit the ability to draw definitive comparisons regarding the impacts of legislation. Outcomes in individual nations are not directly interchangeable; policy on the sex trade does not exist in a vacuum, and the diverse conditions that support these three paradigms limit the generalizability of these results. However, despite the vastly different circumstances that FSW face in South Africa, Sweden and New Zealand, there were recurring themes in all three countries that are indicative of global trends.

Stigma

Social stigma against sex workers is prominent in all three countries and is impacted by their respective legal status. The United Nations Population Fund states, “Deeply entrenched social standards marginalize sex workers and seriously limit their access to quality health services.”38 Even where legal systems attempt to enforce the legal rights of sex workers, fear of judgment still prevents many women from fully engaging with the healthcare system. An observational study conducted at the St James infirmary in San Francisco between 1999 and 2004 assessed the extent to which stigma impacts sex worker’s likelihood of disclosing their profession to a healthcare provider in an environment in which sex work is prohibited. 70% of the 783 sex workers polled had never revealed their involvement in the trade with a health care provider. The authors state, “The reasons for not disclosing one’s sex work history included negative past experiences with disclosure (4.8%), fear of disapproval (31.2%), embarrassment (7.6%) and not thinking their sex work was relevant to their health needs (31.8%).”39 This pervasive fear of disclosure is mirrored in communities of sex workers all over the world and introduces additional barriers for those attempting to obtain health and social services.

The stigma associated with the trade not only promotes disdain and violence toward sex workers, but also forces many underground, where they are less visible to outreach workers and less likely to receive essential services. According to the results of a needs assessment of Canadian sex workers, “When sex workers do not disclose their involvement in the trade, they increase their chances of not having their health and social needs met, do not receive preventative care and may not be referred to appropriate medical and social services to address other issues which they may be facing.”40 The hesitancy of these women to disclose their profession to
healthcare providers has serious consequences, specifically for street-based workers.

While stigma negatively impacts the lives of sex workers in politically sympathetic states such as New Zealand, the legal rights bestowed upon them validate their profession and limit the tangible impacts of stigma. FSW in Sweden occupy a more ambiguous role: while the state tolerates them, it simultaneously imposes a victim narrative upon all women involved in the sex trade. In contrast, South African sex workers are either ignored by the state or are direct targets of its persecution. These policies contribute to a culture that views them as subhuman and treats them as such.

While outcomes for sex workers in South Africa, Sweden and New Zealand reveal that social normalization of the industry via legalization is a significant factor in eradicating stigma, it also brings to light the damaging impact of the generalized contempt for the sex trade around the world. In order to realize the full benefits of decriminalization, administrations must actively engage with society’s perception of sex work as a legitimate profession.

Economic and Health Disparities

Sex workers in New Zealand, Sweden and South Africa all experience economic inequity to varying degrees, both within their communities as well as in relation to the general population. Policies that seek to penalize sex workers or target the demand for sex undermine the health of FSW by crippling their earning ability. In a 013 report entitled Health Care Among Street-Involved Women, Vicky Bungay, Associate Professor at the University of British Columbia, states, “Poverty, for instance, remains the most common shared experience among street-involved women.”41 Reducing health disparities for street-based workers would entail the legitimization of the market for their services and the provision of adequate resources. However, it is clear that the economic insecurity that forces some women into survival sex work is not a phenomenon that can be addressed solely with decriminalization.

In 2008, the Office of Police Integrity in Victoria, Australia conducted an extensive literature review and in-depth interviews with police, sex worker organizations and other stakeholders. The subsequent report, entitled Risk Mitigation in High-risk Environments: street sex workers, found that street-based sex workers are more likely to experience aggravated sexual assault, unlawful imprisonment, kidnapping, robbery and non-payment than non-street-based sex workers. In New Zealand, street-based sex workers were more likely than non-street-based workers to have experienced the following adverse events: “refusal of a client to pay; having money stolen by a client; been physically assaulted by a client; threatened by someone with physical violence; held against their will; been raped by a client.”38 The study goes on to report that street-based sex workers were the most at risk and were significantly more likely to report accepting alternative forms of payment, such as food or shelter, than non-street based workers. The authors note that this was a clear indication of the elevated levels of poverty and homelessness amongst street workers compared to other sex workers.42 A series of qualitative interviews conducted with sex workers in and around Sydney Australia found that 81% of the 72 respondents reported having experienced work-related violence, compared with only 48% of non-street based workers.43 99% of the street-based workers in this study reported having experienced at least one traumatic event in their lifetime, and 93% reported experiencing multiple traumas. The authors also conducted a review of existing literature and found ample evidence that drug-use among street-based sex workers is higher than that of the general population.

Similar evidence of diminished earning power and heightened risk for street-based sex workers has been found in other nations as well. Researchers in a 1999 study on social organization of sex workers in Russia assessed the hierarchy of sex work and estimated the following remuneration scale in Moscow: “Hotel sex workers (US$50 to US$200 per client); brothel, massage parlor and sauna sex workers (US$26 to US$150 per client); street sex workers (US$50 to US$100 per client); truck stop sex workers (US$4 to US$6 per client); and railway station sex workers (crust of bread to US$6 per client).”44 The study found that the workers with the lowest earning power were more susceptible to STIs and abuse from clients.

The lack of social capital and the perceived inability to turn clients away has real health implications for this population. Studies show an inverse correlation between income level and HIV prevalence among sex workers.41 Additionally, there is a correlation among street-based sex workers and the likelihood of developing chronic problematic substance use and mental health disorders. A multitude of studies have found that street-based sex workers are significantly more likely to be using drugs than in other sex sectors in the UK, Australia, Canada, Vietnam and New Zealand.45, 43, 40, 46, 35 A cross sectional study on Posttraumatic Stress Disorder (PTSD) among street-based FSW in Sydney state, “Problematic substance use is also likely to complicate PTSD and response to treatment among street-based sex workers.”43

There is evidence that workers who operate in private settings, such as brothels, tend to be more economically stable than their street-based counterparts.41 The seemingly universal hierarchy of sex work corresponds with declining access and/or utilization of social services and demonstrates a need for low-threshold interventions that are targeted at the most marginalized sex workers. There are numerous harm reduction tactics that have proven effective in addressing these barriers for higher risk sex workers.

Innovative Approaches

Researchers, governments, multilateral organizations and NGOs have developed various strategies to help empower sex workers and combat discrimination. In a review of stigma against sex workers in Hong Kong, authors Wong, Holroyd and Bingham lay out a three-stage approach to address stigma. While sex work is not explicitly illegal in Hong Kong, the government considers most ancillary activities associated with sex work, such as ”keeping an establishment of vice,” or “living on the earnings of prostitution,” to be illegal.47 The first phase of Wong, Holroyd and Bingham’s plan is to create campaigns which remove “the ‘moral dilemma’ associated with sex work by drawing comparisons to other professions, such as service industry workers.47 For the next phase, the authors cite a 2006 study by Flora Cornish of the London School of Economics. This research found that the impacts of stigma on sex workers were lessened by campaigns that drew comparisons with professional groups that have had similar struggles in mainstream legitimization, such as trade unions. The final stage of the strategy calls for collectivization of sex workers in order to garner public awareness, accrue political leverage, and demonstrate successful “alternative ways of life” compared to those that have historically been considered to be culturally acceptable.47

Studies of Community-Led Structural Interventions (CLSI) also show promising results for lessening the impact of stigma. This model provides sex workers with training in skills that can be used to organize a cohesive grassroots movement with the goal of fundamentally altering the systems of oppression. Care-Saksham, a Southern Indian confederation of 10 community-based organizations (CBOs) is one CLSI that has witnessed considerable success in combating sex worker discrimination.48 Funded by the Bill and Melinda Gates Foundation, this initiative has an educational and empowerment component that has been successful in combating HIV and STI transmission by tackling both internalized and external sources of stigma. The program started by identifying 32 social change agents in both rural and urban settings and training them to develop and manage the program within three years.48 This multifaceted intervention, which now consists of about 2,890 sex workers, includes condom distribution, STI treatment, peer education, community building and advocacy work with police and the media to spread positive portrayals of sex workers. One street-based sex worker reports;
“Once, a sex worker who I knew took a party [client] to a lodge. The police came there. I was there but I hid in the bathroom. The police took her and wrote in bold letters on a slate that she is a prostitute and hung it in her neck and made her walk. They threatened that she should not be seen again. We saw the problem but could not do anything. Our sympathy was with her but we could not approach her as we were not intelligent then and we were also afraid. Now we have our CBO. I can say boldly I am from Nari-Saksham [a division of Care-Saksham], a sex workers’ organization. We do not let the police harass sex workers like that.48

Some communities have also undertaken large-scale efforts aimed at poverty-alleviation among high-risk workers. One such measure is the collectivization of sex industry workers. Workers in many countries have banded together to form unions or organizations in order to gain bargaining power and to better advocate for their own interests. The Rose Alliance, a Swedish sex worker organization, was incorporated in 2009 after decades of failed efforts to unionize.49 The Rose Alliance is a member of larger representative bodies including both the International Committee on the Rights of Sex Workers in Europe (ICRSW) and the Global Network of Sex Workers (NSWP).50 This collective recently published a letter of support for Amnesty International’s call for the global decriminalization of sex work stating, “We might not feel valued in our own country, but it would be invaluable to have Amnesty International stand firmly by our side reminding the world that our experiences are valid and what we have to say is important.”49 The New Zealand Prostitutes Collective also provides benefits to its members including community drop-in services, sexual health clinics, needle exchange services, legal and tax advice and information on starting a brothel.35

Another intervention which has had much documented success is street-based harm reduction outreach. This model provides pragmatic and low threshold services aimed to lower the inherent risks in sex work. In 2001, the Open Society Institute (OSI) funded the International Harm Reduction program (IHRD). This pilot program selected 33 organizations from 12 Eastern European countries to deliver services and materials to high risk sex workers in the areas where they work.51 Each organization was tasked with engaging workers in initial and follow up informational sessions, counseling and referrals, legal advocacy, HIV and STI testing and treatment, and other harm reduction interventions. While some programs experienced difficulties in executing the initiative, namely with administrative and safety concerns, the pilot exceeded expectations during its first six months: “Compared to a targeted mid-year goal of approximately 5,700 sex workers reached and 3,500 sex workers engaged in services, the 30 projects reported reaching a total of 6,421 sex workers at least once with any form of outreach or service, and reported engaging 6,254 sex workers in follow-up harm reduction activity.”51

The establishment of safe houses is another initiative that has been adopted in places where sex work is wholly or quasi-legalized. These regulated spaces offer street-based workers a safer place to take clients as opposed to working on the street, out of cars or in public places. In Sydney, Australia, safe houses charge around $13 an hour and offer free condoms, clean syringes and safer sex information.42 In some countries where they exist, safe houses are subject to the same laws that govern brothels, while others are under less scrutiny. The results of this intervention have been varied. New Zealand’s safe house initiative was piloted in Christchurch but was shuttered due to a high level of criminal activity stemming from mismanagement. Sydney’s safe house initiative has had greater success in engaging the population. A 2005 study found that more than half of the 72 women interviewed had utilized safe houses.43 The researchers, however, call for further investigation as to why these spaces are underused.

Conclusion

The continuum of policies that span South Africa, Sweden and New Zealand embody three divergent paradigms on sex work policy. This analysis of legal systems demonstrates a correlation between increased criminalization and declining health and working outcomes for FSW. Evidence points to a reduced risk of disease transmission and violence where sex work is decriminalized, as well as a greater sense of autonomy and engagement with preventative services for sex workers. Relations between FSW and police are more amicable where workers have legal recognition and are confident that the judicial system is working to protect them and not against them. Additionally, FSW were found to have greater economic stability and have better health outcomes in states where the demand for their services is not targeted by law enforcement.

However, despite the varied outcomes of legal approaches to sex work, stigma and economic instability are ubiquitous across all three countries and have been found to contribute to poorer health outcomes around the globe. This effect is magnified among the world’s 42 million sex workers, who are already one of the most marginalized and least visible populations in society.52 Although legal structures significantly impact the lives of sex workers, in order to truly address the needs of this population it is necessary to challenge the health disparities perpetuated by stigma and health disparities endured by sex workers around the globe.

While health conditions for sex workers seem to improve where there are fewer legal restrictions, legislation alone will not ensure that this population’s needs are met. The recent resurgence of support for sex workers and political backing of decriminalization have positive implications for sex workers and the protection of their rights and health. However, the benefits provided by collectivization and low-threshold harm reduction services are precluded by the legal status of the trade. Until sex workers have more state-sanctioned support, efforts to enhance their health and wellbeing will be inhibited.

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