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Editorial: Sex workers to pay the price

BMJ  2006;332:190-191 (28 January), doi:10.1136/bmj.332.7535.190

UK plans to cut street prostitution will threaten sex workers' health

In 2004 the UK Home Office published a consultation paper on sex work, after a review of the Sex Offences Act (2003). The paper, Paying the Price,1 was criticised by specialist services for giving less priority to the health of sex workers than before and for focusing too much on issues of criminal justice, and by health researchers for its unethical use of questionnaires and interviews. The resulting Home Office strategy2 published last week aims to challenge the view that street prostitution is inevitable; achieve an overall reduction in street prostitution; improve the safety and quality of life of communities affected by prostitution, including those directly involved in street sex markets; and reduce all forms of commercial sexual exploitation.

The strategy looks to the controversial Swedish model that criminalises men who pay for sex, and uses police photographs of sex acts and possession of condoms as evidence of sex work. This discourages sex workers from using condoms and introduces tension and potentially violence between them and clients. The Home Office proposes a range of approaches for a variety of sex markets, based on the sex of workers and the locations where sex workers and clients meet. But the strategy does not explicitly tackle health and human rights and will not, therefore, tackle genuine areas of vulnerability and exploitation. Currently, children are sexually abused, people are trafficked and enslaved, and vulnerable individuals, including those with drug dependency or mental health conditions, are coerced and controlled, often by organised criminal gangs. Neither adult sex workers nor clients dare to report these abuses for fear of exposing their own involvement in sex work.

The proposed strategy rejects calls to license premises which comply with ordinary requirements of workplace legislation on health, safety, and labour. A licensing system could ensure that children were not employed, employees were not in possession of drugs, and foreign nationals had work permits.

Instead the strategy focuses on disrupting street sex markets. Kerb crawling will be policed in established red light areas despite strong evidence that this will simply displace sex work to other locations and increase the prevalence of acquisitive crime.3 This will also reduce sex workers' negotiating powers, make it harder for them to find clients, increase their time on the streets, and force them to solicit more directly— increasing the risk of causing offence or distress to people not looking for paid sex. These conditions are directly linked to increased violence, pressure to abandon safer sex practices, and increased public disorder, including vigilante attacks.4

Sex workers are now uncertain about their legal status and are unsure whether the new Home Office strategy has become law. Outreach services and health researchers have noted increased fears among sex workers regarding the safety and confidentiality of such services.

Specialist healthcare services in red light areas face an uncertain future. Outreach work, provision of condoms, needle exchange schemes, and primary care for a population rarely registered with a general practitioner could be compromised if the strategy is enforced and sex workers become reluctant to seek help. Without access to specialist fast track services for sexual health, sex workers may face delays in receiving treatment for sexually transmitted infections, which could have profound consequences both for sex workers and the wider population.

The recent increase in sexually transmitted infections in the general population in the United Kingdom contrasts with a reduced prevalence in female sex workers.5 And the prevalence of HIV infection in sex workers, mainly associated with injecting drug use, remains low— between 0% and 3.5%.5 Sex workers have a responsible approach to managing the risk of sexually transmitted infections, with a high prevalence of condom use for commercial vaginal sex (98%). The Home Office strategy shows inadequate understanding of risk, and the proposed changes could increase negative health outcomes, while limiting patients' access.

Multiagency work by healthcare professionals, police, social services, and sex workers will be disrupted if red light areas are phased out as the strategists intend. This will increase the risks to sex workers, 87 of whom have been murdered in the United Kingdom since 1990.6 Collaborative working gives sex workers the support to report violent clients and other predators who aim to coerce and control them. The lack of detail in the strategy about implementing the new approaches, especially regarding indoor sex work, leaves most of the sex workers we have spoken to feeling uneasy that they will have to wait and see how the strategy affects their access to health care and their contact with the criminal justice system.

Petra Boynton, non-clinical lecturer in healthcare research

University College London
(p.boynton@pcps.ucl.ac.uk )

Linda Cusick, reader in substance use

Institute for Applied Social and Health Research, University of Paisley
(linda.cusick@paisley.ac.uk )


Competing interests: LC is the academic representative on the board of the UK Network of Sex Work Projects.

Reviews p 245

References

  1. Home Office. Paying the price. London: Home Office, 2004. www.homeoffice.gov.uk/documents/paying_the_price.pdf
  2. Home Office. A coordinated prostitution strategy and a summary of responses to paying the price. London: Home Office, 2005. www.homeoffice.gov.uk/documents/cons-paying-the-price
  3. Hubbard P. Community action and the displacement of street prostitution: evidence from British cities. Geoforum 1998;29: 269-86.[CrossRef][ISI]
  4. Sanders T. The risks of street prostitution: punters, police and protesters. Urban Studies 2004;41: 1703-17.[CrossRef][ISI]
  5. Day S, Ward H. Sex work, mobility and health in Europe. London: Kegan Paul, 2004.
  6. Kinnell H. Violence and sex work in Britain. In: Day S, Ward H, eds. Sex work, mobility and health in Europe. London: Kegan Paul, 2004.

Rapid Responses:


 

Prostitution Strategy - A Missed Opportunity 30 January 2006
Sam Ramaiah,
Director of Public Health Medicine/Medical Director
Walsall Teaching Primary Care Trust, Lichfield House, 27-31 Lichfield Street, Walsall, WS1 1TE

Send response to journal:
Re: Prostitution Strategy - A Missed Opportunity
 

 

The safety of sex workers in prostitution as well as the neighbourhoods in which this activity takes place is paramount and therefore there appears to be general agreement that tolerance zones are a better option to achieve this objective. I am therefore like Boynton and Cusik1 disappointed that the Home Office has missed an excellent opportunity to consider this in its strategy.

It may be worth sharing our experience in Walsall which has its own prostitution and associated problems. During the mid 1990’s and late 90’s there was considerable anger amongst the community which was experiencing the direct affects of prostitution. We initiated a qualitative study to obtain the views of residents and sex workers so that a robust strategy could be developed. Findings of this study surprised many as these included hitherto unknown facts. For example more than half the sex workers and their clients were Walsall residents which was contrary to the perception of many that prostitution was an imported problem. This finding alone made individuals and agencies to own the problem. Secondly a large majority of community representatives and sex workers believed that tolerance zones were the best way for safety, health and indeed prevention.2

A multi-agency task group has been in existence led by the police for implementing many of the recommendations arising out of this study. It is true to say that the prostitution problem and its impact on the community are better managed and a great deal of trust has been established. Some innovative programmes have been initiated involving theatre in education programme in schools to discourage children from prostitution; community arts team intervention to identify sex workers aspirations and an active rehabilitation process. Clearly we could not pursue tolerance zone proposal as there was no legal framework to do so. Hence my frustration with the current strategy.

Sex work is an extremely dangerous activity and the use of harm reduction principles can help to safeguard sex workers lives.3 An opportunity to establish tolerance zones as an effective option in this process has been lost in the recent strategy.

References 1 Boynton P. Cusik L. Sex Workers to Pay the Price. British Medical Journal, 2006, 332, 190-192 (28 January 2006).

2 O’Neill M, Campbell R, James A et al. Red Lights and Safety Zones. In Bell D, Jayne M ed. In City of Quarters – Urban Villages in the Contemporary City. Aldershot, Hants, 2004.

3 Rekart ML. Sex Harm Reduction. Lancet, 2005, 366, 2123-2134.

Competing interests: None declared

Second Oldest Crime 4 February 2006
Susan L. Liang,
Hotel manager
Big Surf 96815

Send response to journal:
Re: Second Oldest Crime
 

 

Far from being the oldest profession, prostituting women, girls and boys for their vaginas, rectums or mouths, is the oldest crime next to murder. When the Indo-European steppe nomads came into Europe from the Eurasian steppes, they "plundered" every other tribe -- that is, they stole their resources, which included women and children i.e. they raped and murdered their way into Europe. The Celts were one of these Indo- European peoples.

The still remaining legacy of the Indo-European nomadic tribes to Europe and America is the attitude that those who were and are conquered (or without choice as to whether they should be murdered and/or raped) were of no consequence, being "inferior." From these tribes, we have inherited gender discrimination.... If you go back in history, you will find that most languages share Indo-European roots -- for the reasons above.

To condone rape as it has "evolved" in the present form of sex on demand, is to take the side of the "john" -- the ideologically privileged Indo-European male that he must have what he must have,when he wants to have it, whether it is criminal or not -- even if it involves supporting the pimps/traffickers/assaulters/rapists/murderers in their high lifestyles.

That blurs the line between good and evil, sociologically, and within families, kissing up to males even when they are wrong.

The problem is with insufficient funding for UK prosecutors to go after traffickers and johns.

At war with pimps of children, and children who are now women and men,

Susan Liang Honolulu, Hawaii

Competing interests: Girlfest Hawaii, volunteer Safezone Foundation, volunteer

The prostitute in front of you. 5 February 2006
Steven Ford,
GP
Haydon & Allen Valleys Medical Practice. NE47 6HJ

Send response to journal:
Re: The prostitute in front of you.
 

 

Sir

The average clinician in almost every discipline will have consultations with women (and men) who have used sex to acquire money, goods or services. Which of us gives this much thought - or, come to that, which of us does that exclude? A number of years ago a qualified medical practitioner, who had been engaged in prostitution herself, had an article published in the BMJ - it's beyond belief that she would be unique. What percentage of the population - or our profession - has sought or accepted reward for sex?

Having started, cautiously, to ask the relevant questions as part of a sexual history I have encountered women who have been, who are and who are considering being prostitutes, as well as those who have been offered money for sex without having asked for payment.

Being asked for 'career guidance' in advance of going on the game, was amongst the most uncommon consultations that I have had and, I confess, my first response was that 'Pretty Woman' was not a recruitment video.

Our local GUM service offers quarterly screening for sex workers, I discovered, a frequency that caused one of my patients to circulate around the region's GUM clinics substantially more frequently than that, as well as availing herself of screening with us.

Every GP will have a number of past, present and future prostitutes as patients - do you know who they are? Ought you to know? Are you prepared to provide the relevant care? What is the relevant care?

The government has failed - again - to make real progress on a substantive issue and, again, we, amongst others, will have to contribute to picking up the pieces.

Yours sincerely

Steven Ford

Competing interests: None declared

 

Original link: http://www.bmj.com/cgi/content/full/332/7535/190

 

 

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