Criminalisation, Health, and Labour Rights Among Im/migrant Sex Workers Globally

This chapter introduces the structural determinants that shape health and labour rights among im/migrant sex workers globally. It explores issues related to criminalisation, mandatory health testing, precarious immigration status, economic marginalisation, racialisation, racism and discrimination, language barriers, and gender. This chapter examines how these factors shape health access, health outcomes, and labour rights among im/migrant sex workers in diverse contexts. These issues were explored through a review of academic literature, which was complemented by community consultations that elucidate the lived experiences of gender-diverse im/migrant sex workers from Europe and across the globe. Findings illustrate how shifting sex work criminalisation, public health and immigration regulations (e.g. sex worker registration, mandatory HIV/STI testing), and policing practices impact im/migrant sex workers and shape the labour environments in which they work. The chapter subsequently presents recommendations on policy and programmatic approaches to enhance health access and labour rights among im/migrant sex workers. Finally, it concludes by highlighting the ways in which im/migrant sex workers resist social and structural exclusion, stigma, and ‘victim’ stereotypes, highlighting their tenacity and leadership in the fight to advance labour and human rights among im/migrants and sex workers worldwide.

Reimagining Sex Work Venues: Occupational Health, Safety, and Rights in Indoor Workplaces

The setting in which sex workers live and work is a critical element shaping health outcomes, in so far that different venues afford different sets of risk and protective factors. Understanding how contextual factors differ across venue types and influence health outcomes is thus essential to developing and supporting programmes promoting the rights and safety of people in sex work. In this chapter, we focus primarily on indoor workplaces, with the goals of: (1) elucidating unique social, economic, physical, and policy factors that influence the well-being of sex workers in indoor workplaces; (2) highlighting sex worker-led efforts in the Thai context through a case study of the organisation Empower Thailand; (3) describing best practices for indoor settings; and (4) developing a framework of key factors that must be addressed to improve the rights and safety of sex workers in indoor workplaces, and to support their efforts to organise. The chapter draws attention to convergences and divergences in key challenges that sex workers encounter in indoor venues in different global contexts, as well as opportunities to advance comprehensive occupational health and safety programmes. Indoor venues pose important potential for establishing and implementing occupational health and safety standards in sex work and also may provide substantial opportunity for collective organising given the close proximity of people working together. However, any efforts to improve the health and safety of sex workers must explicitly address the structural conditions that lead to power imbalances and which undermine sex worker agency and equality.

Global Burden of Violence and Other Human Rights Violations Against Sex Workers

Globally, sex workers experience a disproportionate burden of violence and human rights violations linked to criminalisation, punitive law enforcement, and lack of labour protections. Social injustices including poor working conditions, violence and victimisation, police harassment, and discrimination constitute severe violations of sex workers’ health, labour and human rights, and abuses of their freedom and dignity. Policymakers, researchers, and international bodies increasingly recognise violence as a critical public health and human rights concern among the general population; however, human rights violations against sex workers remain largely overlooked within international agendas on violence prevention and in human rights conventions. This chapter provides an overview of the global literature on violence against sex workers, other human rights violations, and drivers of elevated violence and rights inequities across settings. In addition to synthesising global research findings, this chapter features contributions and case studies from community partners in Asia Pacific. Guided by a structural determinants framework, and in recognising the right to live and work free from violence as a human right, this chapter provides an evidence base pertaining to violence against sex workers towards that informs the development of policy and public health interventions to uphold human rights among sex workers worldwide.

Patterns and Epidemiology of Illicit Drug Use Among Sex Workers Globally: A Systematic Review

Introduction: Sex workers who use drugs represent two distinct populations, yet programmatic and policy responses are siloed and failed to acknowledge the ways in which populations overlap and needs intersect. Although prevalence of drug use among sex workers is believed to be higher than the general population, no published estimates of global prevalence exist. We aimed to estimate the prevalence of lifetime illicit drug use among sex workers overall, by gender (cis, transgender, and non-binary), and sub-region.Methods: We searched electronic databases for studies measuring the prevalence of illicit drug use among sex workers from the past decade [2009–2018]. Data were combined to generate pooled prevalence and associated 95% confidence intervals of lifetime use using a random effects model. Countries were categorised into geographic sub-regions, and sub-regional pooled estimates of lifetime use among female sex workers generated and mapped.Results: Among 86 studies in 46 countries, pooled prevalence of lifetime illicit drug use among sex workers was 35% (95% CI 30–41%). There was significant diversity (I2 > 90.0%, P < 0.01), and prevalence ranged from 1.2% to 84%. Most studies reported lifetime drug use among female sex workers (32 studies from 20 countries), and pooled prevalence in this sub-group was 29% (95% CI 24–34%). Insufficient data precluded generation of estimates for male and transgender sex workers.Conclusions: Our review identified significant gaps in data quality and availability. Future research in partnership with sex workers is necessary to explore the diversity of populations and contexts in which drug use and sex work intersect, inform more accurate estimates of prevalence, identify differences in risks and exposures, and guide the creation, implementation, and evaluation of programmes and services.

Best Practices and Challenges to Sex Worker Community Empowerment and Mobilisation Strategies to Promote Health and Human Rights

Sex workers face a number of health and human rights challenges including heightened risk for HIV infection and suboptimal care and treatment outcomes, institutional and interpersonal violence, labour rights violations, and financial insecurity. In response, sex worker-led groups have been formed and sustained across geographic settings to address these challenges and other needs. Over the last several decades, a growing body of literature has shown that community empowerment approaches among sex workers are associated with significant reductions in HIV and other sexually transmitted infections. Yet legal and policy environments, as well as funding constraints, have often limited the reach, along with the impact and sustainability, of such approaches.In this chapter, we first review the literature on community empowerment and mobilisation strategies as a means to collectively address HIV, violence, and other health and human rights issues among sex workers. We then utilise two case studies, developed by the sex worker-led groups APROASE in Mexico and Ashodaya Samithi in India, to illustrate and contextualise community empowerment processes and challenges, including barriers to scale-up. By integrating the global literature with context-specific case studies, we distil lessons learned and recommendations related to community empowerment approaches among sex workers.

Sexual and Reproductive Health and Rights Inequities Among Sex Workers Across the Life Course

All individuals, including sex workers, are entitled to the full spectrum of sexual and reproductive health (SRH) and rights. Yet sex workers continue to bear significant SRH inequities and unmet needs for appropriate SRH services at every step along their sexual and reproductive lives. To illustrate the complex and nuanced barriers that currently impede sex workers’ access to SRH services, this chapter describes the current gaps in access to SRH services experienced by sex workers globally, drawing on in-depth interviews and focus group discussions with 171 sex workers and sex worker organisations from across ten countries. Interviews highlight the lack of tailored, comprehensive, and integrated SRH services. These gaps are driven by intersecting structural forces such as: the criminalisation of sex work, same-sex relationships, and gender non-conformance; harmful and coercive SRH policies; sex work and gender-based stigma; and logistical and practical barriers. To support the SRH needs and rights of sex workers, participants recommended improved access to comprehensive, integrated services addressing sex workers’ broader SRH needs, including family planning, abortion and pregnancy needs, SRH screening, hormone therapy, and other gender-affirming services. Crucial steps towards ensuring equitable SRH access for sex workers include addressing stigma and discrimination within healthcare settings, removal of coercive SRH policies and practices, and dedicating appropriate resources towards sex worker-led SRH models within the context of decriminalisation of sex work.

The Epidemiology of HIV Among Sex Workers Around the World: Implications for Research, Programmes, and Policy

Globally, sex workers of all genders and identities continue to face disproportionately high burdens of HIV, demonstrating the need for programmes better tailoring services to their unmet needs. The reasons for this high burden are complex, intersecting across behavioural, social, and structural realities experienced by sex workers. Here, we build on systematic reviews of HIV among sex workers and case studies rooted in sex workers’ lived experience to describe: (1) the global HIV burden among sex workers; (2) the factors and determinants that influence the HIV burden; (3) intervention coverage and gaps to reduce HIV-related inequities faced by sex workers, over the past decade.Sex workers living with HIV have not benefited enough from significant increases in HIV treatment among the general population. Engagement in this HIV treatment cascade is hindered by structural factors including stigma, migration, policing, criminalisation, and violence, as well as substance use, which present increasingly concurrent risks with HIV among sex workers.Emerging biomedical HIV prevention innovations exist to support the health and human rights of sex workers and reduce onward transmission risk, but persistent data gaps remain, and should be addressed via community-driven implementation research. Epidemiologic research engaging sex workers who are cismen and transgender persons is similarly crucial. Community empowerment approaches have reduced the odds of HIV infection, highlighting the case for greater investments in structural interventions. These investments, combined with filling data gaps and national action towards sex work decriminalisation alongside legal protections, are critical to achieving reductions in sex workers’ HIV burden.

Integrated Interventions to Address Sex Workers’ Needs and Realities: Academic and Community Insights on Incorporating Structural, Behavioural, and Biomedical Approaches

Sex workers experience multi-factorial threats to their physical and mental health. Stigma, human rights violations and occupational exposures to violence, STIs, HIV, and unintended pregnancy create complex health inequities that may not be effectively addressed through programmes or services that focus on a single disease or issue. Meeting cisgender female, male, and transgender sex workers’ unmet needs and realities effectively requires more nuanced, multi-faceted public health approaches. Using a community-informed perspective, this chapter reviews layered multi-component and multi-level interventions that address a combination of structural, behavioural, and biomedical approaches. This chapter addresses (1) what are integrated interventions and why they are important; (2) what types of integrated interventions have been tested and what evidence is available on how integrated interventions have affected health outcomes; (3) what challenges and considerations are important when evaluating integrated interventions. Key findings include the dominance of biomedical and behavioural research among sex workers, which have produced mixed results at achieving impact. There is a need for further incorporation and evaluation of structural intervention components, particularly those identified as highest priority among sex workers, as well as the need for more opportunities for leadership from the sex work community in setting and implementing the research agenda.

Criminalised Interactions with Law Enforcement and Impacts on Health and Safety in the Context of Different Legislative Frameworks Governing Sex Work Globally

This chapter focuses on cis and trans sex workers’ experiences with law enforcement, and how various regimes of regulating sex work including full and partial criminalisation, legalisation, and decriminalisation shape the human rights and the work environments of sex workers globally including access to occupational health and safety, police protection, and legal recourse. Criminalisation and policing of sex work constitute forms of structural violence that perpetuate and exacerbate experiences of interpersonal violence and negative health outcomes among sex workers globally. Country spotlights from the global North and South provide examples of different regimes of regulation and draw attention to how laws and regulations interact with specific work environments in various settings to shape sex workers’ lived experiences of health, safety, and human rights. This chapter highlights how various approaches to criminalising and policing sex work undermine sex workers’ safety, health and human rights, including violence and poor health and concludes with an evidence-based call for the decriminalisation of sex work globally.

Overview and Evidence-Based Recommendations to Address Health and Human Rights Inequities Faced by Sex Workers

This volume uses community case studies and data from around the world to highlight the sustained health and social inequities that sex workers in all of their diversity experience in 2020. Guided by a balanced community–academic partnership, this volume aims to ensure that sex workers’ voices are amplified in describing both challenges and the ways forward. Collectively, the chapters describe an elevated burden of HIV, sexually transmitted infections, drug-related harms, violence and other human rights violations, and significant unmet sexual and reproductive health needs. They also demonstrate that sex workers are not passive recipients of such inequity, but rather actively resist and continue to mobilise to advocate for improved health, safety, and human rights conditions and policy changes. Evidence-based recommendations include sex work decriminalisation, ensuring accessible and sex worker-friendly services, removal of punitive policing and surveillance, community empowerment, and strengthening capacity for community engagement in research, policy, and programmes.