A retreat from human rights? A reflection on sex work's place in contemporary HIV prevention.

In 2012, the World Health Organization guidelines for HIV prevention recommended the decriminalisation of sex work as their number one good practice. Although human rights language played a key role in the international scientific and activist endorsement of the WHO policies, since then there have been few initiatives in terms of advancing the kinds of structural and political changes endorsed. In this Commentary, we reflect on sex work's place in the broader field of the biomedicalization of responses to HIV. The analysis is based on literature reviews and our research trajectories, including preliminary results from a qualitative study on the implementation of PrEP in Rio de Janeiro, Brazil. We argue that sex workers occupy an ambiguous and less visible role in current AIDS policies, and that such policies are increasingly characterised by their prioritisation of biomedical approaches over structural factors. These shifts should be understood as part of a broader, global hegemony of clinical responses to HIV prevention and the continuation of a neoliberal discourse around human rights, without adequate investment in the material conditions necessary to guarantee these rights.

Prostitución, trabajo sexual, justicia y dignidad / Prostitution, sex work, justice and dignity

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Una mirada crítica al abordaje de la prostitución: reflexiones sobre la abolición / No disponible

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[Persons in prostitution situation. Disposition of the own body or human subjectivity as object?] / Las personas en situación de prostitución. ¿Disposición del propio cuerpo o cosificación de la subjetividad humana?

The authors make an interdisciplinary approach to prostitution, with emphasis on women. From the psychological point of view, they adopt a systemic approach, and validate the expression ″persons in prostitution situation″; they review the state of the art in legal matters and public policies, making a critical analysis based on the tradition of realistic thinking. They argue that one of the fundamental issues involved is the unity of the human person and the role that intimacy plays in it, polemicizing against usual objections. Finally, they state their conclusions, which implies affirming that prostitution considers human person as object, and therefore it is contrary to her or his dignity.

Self-reported access to health care, communicable diseases, violence and perception of legal status among online transgender identifying sex workers in the UK.

OBJECTIVES: Transgender-identifying sex workers (TGISWs) are among the most vulnerable groups but are rarely the focus of health research. Here we evaluated perceived barriers to healthcare access, risky sexual behaviours and exposure to violence in the United Kingdom (UK), based on a survey of all workers on BirchPlace, the main transgender sex commerce website in the UK. STUDY DESIGN: The study design used in the study is an opt-in text-message 12-item questionnaire. METHODS: Telephone contacts were harvested from BirchPlace's website (n = 592 unique and active numbers). The questionnaire was distributed with Qualtrics software, resulting in 53 responses. RESULTS: Our survey revealed significant reported barriers to healthcare access, exposure to risky sexual behaviours and to physical violence. Many transgender sex workers reportedly did not receive a sexual screening, and 28% engaged in condomless penetrative sex within the preceding six months, and 68% engaged in condomless oral sex. 17% responded that they felt unable to access health care they believed medically necessary. Half of the participants suggested their quality of life would be improved by law reform. CONCLUSIONS: TGISWs report experiencing a high level of risky sexual behaviour, physical violence and inadequate healthcare access. Despite a National Health System, additional outreach may be needed to ensure access to services by this population.

Popular repugnance contrasts with legal bans on controversial markets.

We study popular attitudes in Germany, Spain, the Philippines, and the United States toward three controversial markets-prostitution, surrogacy, and global kidney exchange (GKE). Of those markets, only prostitution is banned in the United States and the Philippines, and only prostitution is allowed in Germany and Spain. Unlike prostitution, majorities support legalization of surrogacy and GKE in all four countries. So, there is not a simple relation between public support for markets, or bans, and their legal and regulatory status. Because both markets and bans on markets require social support to work well, this sheds light on the prospects for effective regulation of controversial markets.

Can Legislation Alone Protect Devadasi Girls from Child Sexual Abuse and Exploitation?

Girls in India continue to be sexually abused/exploited under the veil of traditional practices such as Devadasi dedication despite the existence of legislation meant to protect them from child sexual abuse. This study recounts the experiences of 30 Devadasi girls who were dedicated, initiated into sexual activity, and involved in commercial sexual activity as children. It underscores the need to address this practice as a criminal offense to be prosecuted under the legislation. Efforts must be made to explicitly connect Devadasi dedication and child sexual abuse in the minds of the public, law enforcement agencies and government officials.

Knowledge, perceptions and attitudes of medical students at the University of Sheffield towards sex workers - a cross-sectional survey.

Sex workers are an 'at-risk' population facing stigmatisation, marginalisation and poorer health outcomes. Their multiple vulnerabilities include substance misuse, mental illness, homelessness, violence, unique health challenges and importantly, barriers to accessing healthcare. Little is known about the opinions of medical students towards sex workers. A 21-item questionnaire was electronically distributed to all medical students at the University of Sheffield in November 2019. The aim was to investigate the knowledge, perceptions, and attitudes of medical students towards sex workers in Sheffield, in the hope of identifying gaps in the medical curriculum and encouraging further research in the area. One hundred and seventy-seven students participated. Students showed a basic awareness of the occurrence of prostitution in Sheffield but lacked detailed knowledge. The vast majority hope that prostitution is legalised in the UK, primarily for the sake of the health and protection of sex workers involved. A significant number of medical students (29% and 23%, respectively) expressed that their attitudes towards treatment of sex workers would not be without pre-judgement or differential treatment. Clearly, this needs to be addressed. Nonetheless, students expressed a desire for further teaching and training to supplement their current knowledge and to better understand the issues related to sex work.Abbreviations: UK: United Kingdom; GMC: General Medical Council.

The impact of end-demand legislation on sex workers' access to health and sex worker-led services: A community-based prospective cohort study in Canada.

BACKGROUND: Following a global wave of end-demand criminalization of sex work, the Protection of Communities and Exploited Persons Act (PCEPA) was implemented in Canada, which has implications for the health and safety of sex workers. This study aimed to evaluate the impact of the PCEPA on sex workers' access to health, violence, and sex worker-led services. METHODS: Longitudinal data were drawn from a community-based cohort of ~900 cis and trans women sex workers in Vancouver, Canada. Multivariable logistic regression examined the independent effect of the post-PCEPA period (2015-2017) versus the pre-PCEPA period (2010-2013) on time-updated measures of sex workers' access to health, violence supports, and sex worker/community-led services. RESULTS: The PCEPA was independently correlated with reduced odds of having access to health services when needed (AOR 0.59; 95%CI: 0.45-0.78) and community-led services (AOR 0.77; 95%CI: 0.62-0.95). Among sex workers who experienced physical violence/sexual violence or trauma, there was no significant difference in access to counseling supports post-PCEPA (AOR 1.24; 95%CI: 0.93-1.64). CONCLUSION: Sex workers experienced significantly reduced access to critical health and sex worker/community-led services following implementation of the new laws. Findings suggest end-demand laws may exacerbate and reproduce harms of previous criminalized approaches to sex work in Canada. This study is one of the first globally to evaluate the impact of end-demand approaches to sex work. There is a critical evidence-based need to move away from criminalization of sex work worldwide to ensure full labor and human rights for sex workers. Findings warn against adopting end-demand approaches in other cities or jurisdictions.

HIV policy in Italy and recommendations across the HIV care continuum.

The HIV epidemic has not yet ended, and there are ever more challenges: the recent Italian National Plan of Interventions against HIV and AIDS (Piano Nazionale di Interventi Contro HIV e AIDS (PNAIDS) 2017-2019) was hailed for its comprehensiveness. Its likelihood of success across the HIV care continuum was therefore assessed. Awareness interventions are sporadic and continue to miss high risk populations; if effectively implemented, the prescriptive detail in PNAIDS may help address this. Combined prevention needs greater focus and investment. However, there has been recent progress: free anonymous testing is available at multiple settings although improvements to provide access to key vulnerable populations are needed. Clinical management is available to a high standard across the country, with some areas for improvement in ensuring equality of access. Long-term management of people living with HIV is often effective, but discrepancies exist across regions and settings of care. It is recommended to enable implementation of PNAIDS as a matter of urgency, develop integrated awareness and testing interventions for STIs and HIV, make condoms free for high-risk populations, and develop a network of multidisciplinary services for long-term holistic care of people living with HIV.

The role of sex work laws and stigmas in increasing HIV risks among sex workers.

Globally HIV incidence is slowing, however HIV epidemics among sex workers are stable or increasing in many settings. While laws governing sex work are considered structural determinants of HIV, individual-level data assessing this relationship are limited. In this study, individual-level data are used to assess the relationships of sex work laws and stigmas in increasing HIV risk among female sex workers, and examine the mechanisms by which stigma affects HIV across diverse legal contexts in countries across sub-Saharan Africa. Interviewer-administered socio-behavioral questionnaires and biological testing were conducted with 7259 female sex workers between 2011-2018 across 10 sub-Saharan African countries. These data suggest that increasingly punitive and non-protective laws are associated with prevalent HIV infection and that stigmas and sex work laws may synergistically increase HIV risks. Taken together, these data highlight the fundamental role of evidence-based and human-rights affirming policies towards sex work as part of an effective HIV response.

The Influence of Legal Brothels on Illegal Sexual Service Purchasing Habits: The U.S. Context.

In this study, we use a survey of sex workers' clients to examine the relationship between having paid for services in legal brothels in Nevada and paying for criminalized sexual services among male clients. Using ordinary least squares (OLS) and generalized ordered logistic regression models, the use of legal brothels is found to be negatively related to reported purchasing of criminalized sexual services, regardless of criminal history, income, and most other demographic factors. When tested by criminalized purchase context, purchases made using the Internet, from public, outdoor contacts (such as the street) and indoor, public contacts (like bars), were less likely to occur with brothel experience. This study addresses a critical gap in scholarship on sex workers' clients purchasing choices with consideration to both market choice and frequency of purchase when having been exposed to a legal replacement for an illegal transaction. Implications and areas of further study are discussed.

Examining Recidivism in a Prostitution Diversion Program.

Street-based sex work is criminalized throughout much of the U.S. Diversion programs have shown mixed results. This study examined the effect a quasi-experimental intervention (prostitution diversion program, n = 149) had on prostitution rearrest compared with a waitlist control group (n = 77) among N = 226 individuals arrested for prostitution in Baltimore. In both groups, n = 64 (28.32%) were rearrested for prostitution over 30 months. Tests of differences compared groups with a significant difference in gender only. A Cox proportional hazard model examined differences in survival time (to recidivist prostitution arrest) between individuals in the control and intervention groups at 6, 12, 18, 24, and 30 months. Results indicate that participation in the intervention did not have a significant effect on decreasing prostitution arrests over time. History of prior prostitution arrest was a significant predictor (hazard ration [HR] = 1.12, p = .02) of rearrest.Lack of program success suggests that barriers to exiting prostitution are substantial, despite availability of supportive services, and that diversion programs may not be the best intervention strategy for all sex workers. Future research should identify motivators for exiting and how to reduce exiting barriers.

Sex work and condom use in Soweto, South Africa: a call for community-based interventions with clients.

Despite public health interventions targeting sex workers in an attempt to increase condom use, HIV still remains a significant health issue for those involved in the sex industry in many countries. In this paper, we analyse data collected as part of an ethnographic study of sex work in Soweto, South Africa. We show that the main problems with consistent condom use are clients who threaten violence if sex workers insist on condoms, clients who are 'rough' and refuse to stop intercourse when the condom breaks, and clients who offer to pay more money for unprotected sex. These issues relate to unequal gender norms that disempower female sex workers and dismiss the importance of consent in sexual relationships. The criminalisation of sex work increases vulnerability and reduces sex workers' agency as sex workers are reluctant to report crimes committed against them. Persistent 'whore stigma' adds to this dynamic by dehumanising sex workers. In conclusion, we advocate for decriminalisation and posit that public health interventions aimed at increasing condom use and reducing HIV rates need to specifically engage clients, address unequal gender norms and involve local communities to tackle stigma directed against sex workers.

A specialty court for U.S. youth impacted by commercial sexual exploitation.

BACKGROUND: Specialty courts have emerged as a model of care for U.S. youth impacted by commercial sexual exploitation (CSE) to ensure comprehensive service provision. However, there is a lack of published research that documents the extent to which these programs achieve this goal. OBJECTIVE: We sought to understand a specialty juvenile justice court's role in identifying mental health and substance use treatment needs, providing linkages to services, and facilitating stability for youth with histories of CSE. PARTICIPANTS AND SETTING: We conducted an exhaustive court file review of the 364 participants in a U.S. based juvenile delinquency specialty court for youth affected by CSE. The observation period spanned 2012-2017. METHODS: The research team systematically transferred data from court files into a secure, electronic database. Descriptive statistics and Chisquared tests were calculated to explore potential associations. RESULTS: Participation in the specialty court for youth impacted by CSE suggests an increase in identification of mental health and substance use needs and linkages and referrals to mental health and substance use treatment services. In addition, there was increased stabilization as indicated by decreased substantiated child welfare allegations, fewer running away episodes, and placements and criminal involvement. CONCLUSIONS: Specialty courts that incorporate a multidisciplinary, trauma-informed approach offer a promising intervention model for meeting the high treatment needs of youth impacted by CSE.

Featured counter trafficking program: The law enforcement first responder protocol.

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficking children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes the Law Enforcement First Responder Protocol, which trained law enforcement to recognize youth engaged in sex work as survivors of commercial sexual exploitation, rather than as "prostitutes", and to connect these survivors immediately with social services, advocates, timely medical care and ongoing follow-up.

Post-implementation of a Safe Harbor law in the U.S.: Review of state administrative data.

BACKGROUND: Safe harbor laws have been implemented to change the way systems of care respond to juveniles exploited in commercial sex in the U.S., yet there is little research on the way these laws have impacted the identification and rehabilitation of juveniles. OBJECTIVE: Using administrative data, this study investigates the impact of a safe harbor law enacted in one state in the U.S. PARTICIPANTS AND SETTING: This study examines secondary data on juveniles with prostitution-related charges from 2007 to 2017 (n = 17); juveniles who were screened for human trafficking by juvenile court personnel (n = 56,937); (3) screenings for human trafficking with juveniles in the juvenile justice system (n = 12,223); and (4) juveniles who were reported to the child welfare agency as possible victims of human trafficking (n = 697). The number of criminal cases of human trafficking involving victims under the age of 18 years old from 2007 to 2017 were analyzed by calendar year (n = 61). METHODS: Aggregate, administrative data was accessed and analyzed. RESULTS: Findings show that juvenile justice and juvenile court personnel are screening for trafficking at an increasing rate and making referrals to the child welfare system as mandated by law. However, a relatively low percentage of these cases are substantiated, confirmed and/or result in criminal charges to the trafficker. Despite safe harbor mandates that prohibit the charging of juveniles with prostitution offenses, there is evidence that this is still occurring in small numbers. CONCLUSIONS: Based on these findings, researchers have identified next steps to facilitate future investigations of safe harbor laws.

Sex workers' experiences and occupational conditions post-implementation of end-demand criminalization in Metro Vancouver, Canada.

OBJECTIVES: In 2014, Canada introduced end-demand criminalization (the Protection of Communities and Exploited Persons Act (PCEPA)), criminalizing purchase of sexual services while leaving the sale of sex legal. We assessed factors correlated with self-reported changes in working conditions post-PCEPA among sex workers (SWs) in Metro Vancouver. METHODS: Post-PCEPA data for one year were drawn from a community-based cohort of SWs. We analyzed self-reported changes in working conditions among 299 participants who worked prior to PCEPA and were asked about working conditions post-PCEPA. Multivariate GEE analysis evaluated factors correlated with negative changes post-PCEPA, including reduced capacity to screen clients and reduced access to workspaces/clients. RESULTS: Most (72.2%) experienced no change in working conditions, and 26.4% reported negative changes (e.g., reduced ability to screen clients or reduced access to workspaces/clients). Reporting negative changes was correlated with being an im/migrant to Canada (adjusted odds ratio (AOR) 2.79, 95% CI 1.59-4.92) and recent physical workplace violence (AOR 4.01, 95% CI 1.12-14.40). In sub-analysis, physical/sexual workplace violence (AOR 3.77, 95% CI 1.17-12.16) and living in the suburbs of Richmond/Burnaby (AOR 2.81, 95% CI 1.15-6.84) correlated with reduced screening capacity; incarceration (AOR 2.98, 95% CI 1.04-8.57) and being an im/migrant (AOR 2.39, 95% CI 1.14-4.99) correlated with reduced access to workspaces/clients. CONCLUSIONS: Most SWs reported no change in working conditions and one quarter reported negative changes, suggesting that PCEPA may be failing to advance sex workers' safety. Im/migrants, women experiencing workplace violence, and those facing criminalization were most likely to report negative impacts. Decriminalization of all aspects of sex work is needed to support well-being, health, and safety.