Intended for healthcare professionals


Protection of sex workers

BMJ 2007; 334 doi: (Published 11 January 2007) Cite this as: BMJ 2007;334:52
  1. Michael D E Goodyear, assistant professor (mgoodyear{at},
  2. Linda Cusick, reader in substance use2
  1. 1Department of Medicine and Women's Centre, Dalhousie University, NS, Canada B3H 2Y9
  2. 2Institute for Applied Social and Health Research, University of Paisley, PA1 2BE UK

    Decriminalisation could restore public health priorities and human rights

    Between 2 and 12 December 2006, the bodies of five young women—Gemma Adams, Tania Nicol, Anneli Alderton, Paula Clennell, and Annette Nicholls (aged 19-29)—were discovered near Ipswich.w1 Their involvement in street prostitution created a media controversy over whether labelling them as prostitutes was dehumanising, as well as raising questions about our duty to protect such women, and how this can be best achieved.w2 Sex workers and their families have spoken of abuse and violence, and they have added a human face to these women's lives. This has provoked an overdue debate, but the same stereotyping, prejudices, myths, and a failure to appreciate the complexity and diversity of sex work and its social contexts persist.1

    Sex workers around the world continue to be murdered, including about six each year in the United Kingdom.w3 Standardised mortality rates for sex workers are six times those seen in the general population (18 for murder), the highest for any group of women. Death and violence are but part of a spectrum of physical and emotional morbidity endured.2 w4-w7

    At issue are human rights and repressive legislation in the UK, thus inviting comparisons with how other countries protect sex workers. Governments and health and social services have a duty of care without discrimination.3 The UK government failed these women4 w2 w8 by ignoring their voices,w9 and those of researchers, service providers, and organisations,2 5 6 7 including the BMJ,8 9 and by promoting discriminatory laws and practices.4 9 Recent policies on prostitution (such as Paying the price)10 are disturbingly reminiscent of the Victorian Contagious Diseases Acts,11 and specialist services state that these have increased the vulnerability of sex workers.4 9

    Marginalisation and the “violence of stigmatisation”w10 invite victimisation and create barriers to accessing health and social care. The UK government was warned of the consequences of its actions from many quarters, but persisted.4 9 Analysis of 150 years of failed policies in the UK requires an understanding of the barriers to implementing effective broad social policies,12 which do not fit well within the narrow remit of the Home Office.4

    The moral debate on sex work is deeply divisive, often denying both a voice and the ability to make choices to the women at its centre.w10 Radicals and abolitionists believe that prostitution can be eradicated and that removing criminal proscription would institutionalise violence against women and their objectification in sexual slavery. The liberal viewpoint recognises the inevitability and legitimacy of sex work and that choices, even when constrained, are still legitimate.

    Fundamentally this is the wrong debate, because the morality of prostitution is not the issue,w8 for morality is “not the law's business.”13 It is state oppression, constraints of autonomy, and the resulting abuse and exploitation of marginalised women (whatever their occupation) that are the real moral issues, as those who work and care for these women know all to well.

    Ethical analysis of prostitution is further obscured by links4 with other issues including people trafficking, underage sexuality, substance misuse, sexually transmitted disease, and organised crime. These issues must be uncoupled. Even if these claims of related social harm can be verified (and many are disputed4 9), prostitution does not cause these; it is prohibition that turns social issues into criminal ones.14 Prostitution requires no unique legal remedy. The harm then is to the sex workers themselves. John Stuart Mill, who campaigned for repeal of the UK's prostitution laws during the 19th century, stated that demonstration of harm (the harm principle) should be the basis of defining crime, and therefore the basis of law.15 Legal remedies are neither appropriate nor effective in enforcing moral norms or resolving social issues.6 The welfare of these women must always be our primary concern, and the first priority in harm reduction4 14 is the removal of prostitution from criminal law.12 16 w10

    The use of antisocial behaviour orders by the Home Office to control prostitution has also forced women into more dangerous locations and isolated them from support services.4 This must stop,16 together with suspension of the relevant laws, to enable policing to focus on protection rather than prosecution.

    Comparisons have been made with the Netherlands and Germany, but we should be cautious before transposing models between social systems. These approaches have not eradicated harm to workers, but merely shifted its focus. The Swedish model, based on abolition, which criminalises men who purchase sex rather than women who provide it, has influenced the UK government's philosophy, but this model is not grounded in reduction of harm to women,14 16 ignores the welfare of sex workers, and drives markets into more dangerous areas, as in Ipswich.

    Surprisingly absent from most proposals is discussion of New Zealand's decriminalised model.w11 Decriminalisation will not completely eliminate street prostitution, which poses most dangers for women,w4 but it will enhance women's choices, and help to make the streets safer, develop community based support programmes, and improve relations between sex workers and residents.7 Policy details will need to include discussions around issues such as setting aside areas for working (managed zones)7 14 and regulation of premises. In New Zealand and parts of Australia sex work is an occupation with its own health and safety standards. Public health measures must be built on evidence based best practices. Health and social services have an ethical obligation to ensure universality of access to care, to minimise harm to all, and to be advocates for those they provide care for. Criminalisation of prostitution limits access to health and social care and contravenes United Nations' guidelines on human rights.w10 Only by moving prostitution out of the criminal justice system and focusing on public health and social care can we provide optimum support and help to break the cycle of violence.

    The status quo in the UK is unacceptable moral cowardice. The prime minister has opposed reformw8 and stalled demands for the protection of women; he must show leadership and restore human rights by decriminalising all aspects of sex work now.4 12 Legal precedent exists for suspending legislation on prostitution in the 19th century and Helen Clark, New Zealand's Labour prime minister, emphasised that her country's decriminalisation in 2003 was not related to sexual morality but to a duty to place the welfare of the vulnerable and marginalised first.

    Remedies for social issues surrounding prostitution lie not in legislative measures but in social determinants that limit women's choices, such as wage disparities, access to welfare, and domestic violence.14 w9 Labour politicians remind us that the morality of a society will be judged by the way it treats its most vulnerable members,17 yet UK government policies discriminate against the most disadvantaged. Gemma, Tania, Anneli, Paula, and Annette were each some mother's daughterw7 and some were mothers. Their deaths were almost inevitable.9 They deserved better, but we failed them.4 w2 w8 We will honour them best by now doing the right thing.


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


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