Globally, stigma and criminalization inhibit sex workers from accessing healthcare. While long-term policy and cultural changes should be the ultimate goal, harm reduction can provide a short-term solution.
As COVID-19 continues to wreak havoc on global health, it affects socially marginalized and vulnerable people the most. This includes migrant sex workers, who make up the vast majority of sex workers in Europe. First of all, many of them haven’t been able to afford to stop working – leaving them more exposed to contracting COVID-19 as well as suffering the mental health effects of working despite the risk. Secondly, the majority of sex workers around the world aren’t eligible for government assistance during COVID-19, since sex work often isn’t recognized as work and undocumented migrants aren’t eligible for many social support services. Finally, social distancing regulations have compromised the ability of grassroots organizations and NGOs to provide healthcare services (i.e. handing out condoms or hand sanitizer).
The problem is that COVID-19’s serious healthcare implications for sex workers, particularly migrant sex workers, don’t come from nowhere. They exacerbate a persistent issue: a variety of complex, intersecting, sociopolitical factors hinder this population from accessing healthcare – which is a human rights violation. WHO defines the universal right to health as a human right, inclusive of the right to freedoms and entitlements. But vulnerable sex workers do not have the luxury of enjoying this human right. I argue that it’s our collective responsibility from a human rights perspective to implement healthcare solutions for this group – especially given the urgency of sex workers’ significant plight during the COVID-19 pandemic. Although long-term solutions are the ultimate goal in terms of enabling this group of people to access the human right of health on a permanent basis, short-term solutions can alleviate some of their struggles today.
Who I am
My perspective is rooted in my work as a journalist focusing on sex workers’ rights and my experience as a sex workers’ rights activist. Since 2017, I’ve been a volunteer at The Red Van – a harm reduction initiative and NGO providing street-based sex workers in Copenhagen, Denmark with an indoor space to work from as well as healthcare supplies. As a result, my recommendations for short-term solutions are rooted in harm reduction principles we’ve employed at The Red Van since day one. The long-term solutions, on the other hand, build on the significant body of work and activism done by sex workers and their allies worldwide regarding sex workers’ access to human rights and healthcare. The recommendations are not my ideas; they are my attempt at recognizing and listening to sex workers’ own demands and solutions.
It is important to note that the following recommendations are by no means exhaustive; they merely offer an entry point into thinking about ethical and effective healthcare solutions for sex workers. Moreover, my perspective is rooted in my specific knowledge base. I have engaged in sex workers’ rights exclusively in a European context, so my opinions are geared towards Europe; I cannot suggest the best solutions for other places in the world. Finally, I am not a sex worker but an ally. While my recommendations are informed by experience in the field, ultimately, sex workers know best about the healthcare solutions they need.
The healthcare plight of sex workers
Sex workers struggle to access healthcare due to a variety of intersecting issues. Perhaps the most influential are stigma and criminalization.
Stigma against sex workers is almost universal. It impacts everything: their ability to access worker protections and housing, their personal relationships, their ability to disclose their identities, and their access to healthcare. In addition, stigma against sex work exacerbates other social stigmas. For example, undocumented, transgender sex workers of color are some of the most marginalized people in the world.
Stigma against sex workers shows up as mandatory STD/STI checks in countries such as Austria and Greece; these reinforce the idea that sex workers are “vectors of disease”, whose bodies are sites of danger and must be regulated by outside parties (1). It also permeates in the treatment that sex workers receive from healthcare providers; many sex workers have reported being ridiculed by their providers, or having their personal data exposed without their consent. As a result, many sex workers refrain from disclosing their occupation to their healthcare providers – which further distances them from the medical support they’re entitled to.
In addition to this, criminalization of sex work is the key hurdle inhibiting sex workers’ access to healthcare. Many countries criminalize sex work. For example, countries like the US fully criminalize sex work, meaning that buying and selling sex is illegal. In the past ten years or so, however, nations such as Canada and France have adopted the Swedish model, which partially criminalizes sex work. Under this system, selling sex is legal while buying is illegal. While full criminalization and the Swedish model have their differences, they have multiple problems in common. Both render sex workers’ lives more dangerous, and both inhibit their access to healthcare.
For example, these models compromise sex workers’ abilities to use condoms. In countries which fully criminalize sex work, sex workers can be reluctant to carry condoms because condom possession can be reason enough for the police to charge you with breaking the law due to selling sex, soliciting or loitering. And in countries that employ the Swedish model, sex workers are particularly at risk because of customer pressure to have sex without a condom; they also suffer because abolitionist associations are reluctant to hand out condoms in the first place, since they see this as supporting prostitution (2). In addition, sex workers in criminalized environments can struggle to earn enough because there are fewer safe customers to choose from and fewer safe places to work from: as a result, many sex workers cannot afford the cost of healthcare services, or to take time off work to tend to their health needs.
Countries which criminalize sex work also tend to criminalize sex work-adjacent activities, which impacts sex workers and limits the effectiveness of NGOs and grassroot organizations. For example, Denmark and France both have the Procurement law in place; widely known as the “anti-pimping law”, it prohibits benefiting from sex work as a third party. For sex workers, this means they can’t work together for increased safety, because that would be considered brothel keeping; they also struggle to rent apartments, because landlords could be charged with pimping. The other problem is that the definition is so broad and vague that many NGOs and grassroots organizations are unsure of whether their activities could count as breaking the law or not. In Denmark, the Procurement Law stops our team at The Red Van from advertising our opening hours or saying explicitly that we are available to hand out condoms: we simply aren’t sure whether or not we’d be breaking the law by doing so. Over the long term, this renders our services more fragmented: we have to reach street-based sex workers by word of mouth and on foot whenever we are open – which is not the most efficient way of making our services and healthcare provisions accessible for all.
Finally, policies that criminalize sex work support socially entrenched stigma against sex workers. This creates a catch-22 situation: the more stigma against sex work, the more likely a country is to criminalize it. But the more a country criminalizes sex work, the more that stigma and its unique impacts on sex worker access to healthcare are maintained. One of the most glaring results is increased danger and risk of harm: sex workers in criminalized environments routinely report experiencing more and more violence from customers. This violence takes the form of assault and theft, but also as a lack of willingness to wear condoms or even removing a condom mid-sex without the sex worker’s consent. When sex workers are pressured or coerced into condomless sex, they are exposed to health issues such as unwanted pregnancy or STIs like HIV. Although data about the prevalence of HIV amongst sex workers in Europe is scarce, a study found that female sex workers have a 13.5 times greater chance of HIV infection than women in the general population (2).
Short-term solution: Harm Reduction
Harm reduction is a public health approach that aims to reduce harm associated with certain behaviors or contexts (3). The goal is not to eliminate the root cause of the harm, but to alleviate its negative consequences in a compassionate and effective way. Although harm reduction is most commonly considered within the context of drug use – safe injection sites are an example of harm reduction – its underlying principles can be translated to fill the healthcare gap in other risky situations. This includes street-based sex work. While long-term solutions such as decriminalizing sex work and destigmatizing people who sell sex should be the goal, these changes simply aren’t being implemented fast enough. With that in mind, harm reduction provides an opportunity to implement healthcare solutions quickly, which at the very least alleviate some of the issues that street-based sex workers face. To exemplify this, I’ll outline how The Red Van works with harm reduction.
First of all, we provide street-based sex workers with a refurbished van that serves as an indoor space from which they can work. The concept is straightforward: by providing sex workers with an indoor space to work from, we reduce their risk of harm on the job. Research demonstrates that sex workers who work inside are safer: for example, a report by the Danish National Centre for Social Research found that 41 percent of Danish street workers have been sexually assaulted by customers, compared to three percent of sex workers who operate indoors. Moreover, our van creates a neutral power dynamic between sex workers and the customers – a key method for reducing harm. Studies have shown that when sex workers meet their customers in a ‘neutral’ space, a customer is less likely to become violent (4). So, unlike a car, which is the customer’s space, our van puts sex workers and their customers on equal footing.
Secondly, our van is designed with interventions for safety in mind. On the one hand, it’s always stocked with condoms, disinfectant and lube; on the other, small details help reduce the risk of harm even more. We have a knee pillow available to make blowjobs more comfortable. The van is very well-lit, which helps sex workers read their customers more accurately. And the van isn’t quite sound-proof: it’s quiet enough that nobody hears the details of any customer interaction happening inside – but if a sex worker or a customer raises their voice, our team of volunteers can hear it and respond if necessary.
Finally, we never ask for documentation or data from anybody using the van – which encourages our van’s use in a significant way. Sex workers know that when they use our van, they don’t have to worry about their personal data being shared with third parties – something that many sex workers are weary of due to stigma and insecurity around their legal status as workers.
Besides the van itself, our team walks around the street sex worker area in Copenhagen and hands out condoms and lube. And during COVID-19, we’ve also started handing out hand sanitizer and masks.
The Red Van is an entirely volunteer-run operation that exists on a minimal budget. With a small amount of funding, we’re able to maintain the van and continue providing condoms, lube and more. This proves that harm reduction doesn’t have to be complicated or expensive: as long as your intervention addresses a specific healthcare barrier, it can be effective. While The Red Van and other harm reduction initiatives for sex workers aren’t a fix-all, they do provide a short-term solution for environments that lack the long-term changes necessary.
Long-term solutions: Full destigmatization and decriminalization
The two biggest factors inhibiting sex workers’ access to healthcare are stigma and criminalization. Overcoming them is key to ensuring that sex workers have consistent, contextually specific, applicable and safe access to healthcare over the long term. But what does overcoming them look like?
Recognizing sex work as work
Culturally and politically, few places in the world view sex work as work. For instance, in countries operating under the Swedish model, sex work is seen as prostitution – a social problem that must be abolished. This exacerbates stigma against sex work, which affects sex workers’ abilities to know what their rights are: for example, French sex workers were unaware that they were eligible to apply for government assistance during COVID because stigma made them assume they wouldn’t be. And in countries like Denmark, where buying and selling sex are legal but procuring is not, sex work occupies a grey area. Sex workers must pay taxes, but aren’t afforded many of the same rights as other workers; and sex work is still debated as a social issue in the media.
In order for sex workers to be fully aware of their rights and entitled to the same healthcare as other citizens, sex work must be recognized as work in our cultural understanding and in our policies. Once sex work is acknowledged as labor, sex workers will increasingly be viewed as people worthy of rights, protections and dignified healthcare – like all other workers. This is especially crucial for financially supporting sex workers during situations that limit their abilities to earn money, such as the COVID-19 pandemic. Once sex work is seen as work, the stigma barrier will begin to crumble.
Meaningfully including sex workers in the development of healthcare solutions
Globally, sex workers are often excluded from decision-making about them. Not only does this reinforce stigma against sex work by implying that their opinions don’t matter, but it’s also ineffective. Sex workers are the experts in their own lives and know the solutions that would work best for them, including healthcare. Meaningfully including sex workers in healthcare programs or solution development is fundamental to meet their needs in a way that is dependent on context. Without their meaningful inclusion, potential interventions will likely fail or repeat the mistakes of previous solutions. To start including sex workers in healthcare development, current healthcare providers should begin to establish trust with them. That can look like partnering with sex worker-led organizations and viewing sex workers as potential healthcare providers, too. Finally, they should make a continuous effort to listen to sex workers across different identities. Only then will they ensure that the solutions they implement are effective for people with unique and varied healthcare needs, such as transgender sex workers or sex workers living with HIV/AIDS.
Fully decriminalizing sex work
Last but definitely not least, removing all criminal penalties related to sex work is the best approach for protecting sex workers’ human rights. Full decriminalization means that sex workers won’t have to fear arrest or be arrested. They’ll be able to work together, which will ensure they aren’t isolated in case a customer interaction goes awry. And from a healthcare perspective, they’ll be able to confidently carry condoms and disclose their profession to their healthcare providers – knowing that it won’t get them in trouble. Decriminalizing sex work is the main tool for ensuring that sex workers are viewed and treated as workers worthy of rights, protections, and dignified services from all perspectives – including healthcare.
Globally, sex workers face a multitude of barriers inhibiting their access to consistent and dignified healthcare. While long-term changes such as decriminalizing sex work are the goal, our policymakers aren’t implementing them fast enough. To fill the ‘healthcare gap’ that affects sex workers, particularly migrant sex workers, short-term solutions should be employed. A reliable starting point is harm reduction, which The Red Van has been effectively providing for sex workers since 2016. Harm reduction can alleviate the risk of harm this group faces on the job without relying on a huge budget or significant policy changes. Moreover, it can kick-start the shift towards the long-term changes we need to ensure sex workers’ access to the human right of change: recognizing sex work as work, and destigmatizing their labor and lived experiences.
- Nova, C., “Vectors of Disease: Sex Workers as Bodies to Be Managed”, QED: A Journal in GLBTQ Worldmaking, 2016
- “Potential impact of the Swedish model on rates of HIVAIDS among sex workers and their access to healthcare”, HIV Ireland, 2015.
- Hawk, M. et al., “Harm reduction principles for healthcare settings”, Harm Reduction Journal, 2017.
- Deeding, K.N. et al., “A Systematic Review of the Correlates of Violence Against Sex Workers”, Am J Public Health, 2014.