Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies

Abstract

BackgroundSex 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 findingsWe searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, 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 outcomes 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 condomless 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 extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police 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 reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence 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 conduct meta-analyses for others, as well as variable sample size and study quality. Few studies 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 evidence related to emotional health and access to healthcare beyond HIV/STI testing.ConclusionsT...

Community-Based Responses to Negative Health Impacts of Sexual Humanitarian Anti-Trafficking Policies and the Criminalization of Sex Work and Migration in the US

“…In a meta-analysis by Platt et al (2018) examining over 130 studies in 33 different countries over almost three decades, researchers found higher risks of condomless sex, physical and sexual violence from clients or partners, and HIV/STI infections amongst sex workers who had been exposed to repressive policing, compared to those who had not. Policing practices were also linked to the disruption of work environments, diminished support networks and compromised safety and risk reduction strategies, and limited access to health services and justice (Platt et al 2018).…”

“…In a meta-analysis by Platt et al (2018) examining over 130 studies in 33 different countries over almost three decades, researchers found higher risks of condomless sex, physical and sexual violence from clients or partners, and HIV/STI infections amongst sex workers who had been exposed to repressive policing, compared to those who had not. Policing practices were also linked to the disruption of work environments, diminished support networks and compromised safety and risk reduction strategies, and limited access to health services and justice (Platt et al 2018). In a separate longitudinal study featuring 221 transgender women in Boston and Chicago, researchers noted that participants were disproportionately affected by incarceration (38%), and incarceration predicted participants' negative health outcomes and drug use over time (Hughto et al 2018).…”

Justice and Civil Liberties on Sex Work in Contemporary International Human Rights Law

“…Most obviously, given the emphasis on regional examples, a large systematic review of best evidence from thirty three countries by Platt et al (2018) demonstrating the impact of criminalisation, including client criminalisation, on the health, safety and rights of sex workers was omitted. This meta-analysis showed the extent to which policing practices affect sex workers' safety, health and access to services.…”

Transgender People and Human Trafficking: Intersectional Exclusion of Transgender Migrants and People of Color from Anti-trafficking Protection in the United States

“…An intersectional approach is crucial to understanding how trans migrants and people of color experience the negative effects of criminalization recognized as a contributor to risk of exploitation and trafficking in the sex industry (Platt et al 2018). For instance, in both NYC and LA, cis women viewed by authorities as trafficking victims are subject to arrests, which function as a catalyst for court supervision and referral to mandated social services (Musto, 2016).…”