Decriminalising sex work in the UKBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4459 (Published 16 August 2016) Cite this as: BMJ 2016;354:i4459
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We thank Byng et al for their rapid response. We are pleased that they agree with the need to maintain funding for specialist sex worker services and that the importance of these services lies in their model of integrated care to address the complex needs that sex workers’ experience, as we emphasize in the editorial.(1)
However, Byng et al’s response contains several inaccuracies that are important to address. Firstly, we state that the public health evidence clearly points to the need to decriminalize sex work, specifically the removal of criminal and administrative penalties used as punitive sanctions against sex workers and their clients. This is not the same as proposing a legal model that regulates sex work, as applied in the Netherlands. Byng et al inaccurately conflate this regulatory model, which they refer to as the ‘Dutch model’, with the decriminalized model introduced in New Zealand in 2003 under the Prostitution Reform Act, that we advocate. Evidence from the Netherlands shows that regulatory models that require licenses for brothels make it difficult for sex workers to work independently. The use of mandatory registration with authorities can preclude migrants, effectively creating a two-tier sex industry and failing to protect the most vulnerable sex workers.(2) This is an important parallel discussion, but not one our editorial addressed.
Secondly we do not agree with Byng et al’s categorization of those who hold opposing views on sex work legislation into two strands of feminism: ‘liberals’ and ‘radicals’. Our support of decriminalization does not represent a liberal feminist stance but an ‘intersectional’ one, recognizing that sex workers make decisions in the context of intersecting gender, sexual, ethnic and economic inequalities. (3, 4)
We urge the Home Affairs Select Committee to consider the public health evidence on the impact of the ‘sex buyer law’ that criminalizes the purchase of sex alongside evidence for full decriminalization of the sale and purchase of sex (as implemented in New Zealand), when they are making their final recommendations. We dispute Byng et al’s claim that our support of decriminalization is based on an unbalanced portrayal of the evidence. While we agree that there is a shortage of quantitative evidence to evaluate different sex work policies, and a need for more consultation with sex workers and empirical data to inform policy-making, the growing body of evidence that documents the harms associated with criminalizing sex workers’ clients cannot be ignored.
Qualitative evidence shows how criminalization of clients reproduces vulnerabilities experienced by sex workers in the same way as criminalization of sex workers themselves and can further entrench marginalization. In Canada, soliciting is still displaced into more isolated work areas so that clients can avoid the police, which can disrupt support networks and increase the likelihood of exposure to violence, including forced unprotected sex. Concerns about arrest still reduce time for negotiations over services or screening out potentially dangerous clients with the same consequences.(5) Evidence from Sweden shows that those people who choose or have no choice but to stay in sex work experience increased marginalization, with sex work seen as inherently dangerous. Constructing sex work as a form of violence, the sex-buyer law has been accompanied by an end of harm reduction interventions for sex workers, with the distribution of condoms perceived to be condoning sex work and, as a consequence, perpetuating violence against women.(6) These data are derived from interviews with sex workers, reflecting their lived experiences of the policy and point to harmful unintended consequences, difficult to avoid however carefully implemented.
In contrast, Byng et al do not present any empirical evidence to show that the ‘sex buyer law’ reduces public health harms. They refer (without citation) to evaluations in Sweden that indicate a decline in the number of sex workers as a result of the policy. Other researchers have critiqued governmental evidence that supported this statement, stating that estimates were based on street-based sex workers only and any visible decline in the population was likely due to displacement and relocation to off-street venues.(6) Research shows that estimating the size of ‘hidden’ populations is problematic, so this is an unreliable indicator to use as a measure of effect.(7)
We agree with Byng et al, that violence against sex workers is a major public health concern. In the UK, up to 64% of female sex workers report violence at work(8, 9) and they are 12 times more likely to be murdered than other women their age(10). As we outline in our editorial(1), evidence shows that criminalization of sex work is an important determinant of violence. Sex workers who have experienced any criminalization associated with their work are at up to seven times greater risk of violence compared with those without such experiences across different international settings.(11) However, the implication that all sex work is ’essentially abusive’ not only disrupts services (as seen in Sweden) but fails to recognize the diversity of experience in the sex industry, the complex and varied reasons why people enter sex work, and the possibility that financial reimbursement for sex between adults can be consensual. These misconceptions and the stigma they generate are reinforced through the use of the term ‘prostitute’ as opposed to ‘sex worker’. Sex worker is the preferred term used by sex workers themselves and has been adopted by health and advocacy organizations globally.(12, 13) It acknowledges the labour involved in sex work and can encompass a broad range of experience. In contrast, the term ‘prostitute’ suggests a population without agency and ignores the progress made in the last 40 years as a result of sex worker activism.
Legislation must prioritize sex workers’ safety, health, and access to care, welfare, justice and rights, in recognition of the diverse realities of sex work. We reiterate that the public health evidence strongly supports full decriminalization of sex work, including the avoidance or removal of penalties targeting clients. We also stress that this must be accompanied by inclusive housing, health, welfare and migration policies that tackle broader inequalities and injustices experienced by sex workers and others.
1. Grenfell P, Eastham J, Perry G, Platt L. Decriminalising sex work in the UK. BMJ. 2016;354:i4459.
2. Pitcher J, Wijers M. The impact of different regulatory models on the labour conditions, safety and welfare of indoor-based sex workers. Criminol Crim Justice. 2014;14(5):549-64.
3. Crenshaw K. Mapping the Margins: Intersectionality, Identity Politics, and Violence Against Women of Color. Stanford Law Review. 1991;43:1241-99.
4. Gallagher A. The Challenges Posed by Intersectional Feminism to Radical Feminist Thought. 2016; 2(1): 11-12. . Warwick Sociology Journal. 2016;2(1):11-2.
5. Krusi A, Pacey K, Bird L, Taylor C, Chettiar J, Allan S, Bennett D, Montaner JS, Kerr T, Shannon K. Criminalisation of clients: reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada-a qualitative study. BMJ Open. 2014;4(6):e005191.
6. Levy J, Jakobsson P. Sweden's abolitionist discourse and law: Effects on the dynamics of Swedish sex work and on the lives of Sweden's sex workers. Criminol Crim Justice. 2014;14:593.
7. Cusick L, Kinnell H, Brooks-Gordon B, Campbell R. Wild guesses and conflated meanings? Estimating the size of the sex worker population in Britan. Crit Soc Policy. 2009;29:703-19.
8. Church S, Henderson M, Barnard M, Hart G. Violence by clients towards female prostitutes in different work setting: questionnaire survey. British Medical Journal. 2001;322:524-5.
9. Platt L, Grenfell P, Bonell C, Creighton S, Wellings K, Parry J, Rhodes T. Risk of sexually transmitted infections and violence among indoor-working female sex workers in London: the effect of migration from Eastern Europe. Sexually transmitted infections. 2011;87(5):377-84.
10. Ward H, Day S, Weber J. Risky business: health and safety in the sex industry over a 9 year period. Sexually transmitted infections. 1999;75(5):340-3.
11. Deering KN, Amin A, Shoveller J, Nesbitt A, Garcia-Moreno C, Duff P, Argento E, Shannon K. A systematic review of the correlates of violence against sex workers. American Journal of Public Health. 2014;104(5):e42-54.
12. UNAIDS. Guidance Note on HIV and Sex Work 2009-2012. Geneva: UNAIDS, 2012.
13. World Health Organization. Guidelines: prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries. Geneva: World Health Organisation, 2012.
Competing interests: No competing interests
Re: Decriminalising sex work in the UK. Learning from experience and fully integrated outreach services could make the Nordic model work in the UK.
Grenfell et al make an important case for expanding rather than cutting specialist services for so called ‘sex work’.(1) We agree that outreach as well as clinic based services are critical for limiting individual illness and promoting public health though reduction in infection. We would add that these services need to be well co-ordinated with substance use, mental health and primary and social care teams to maximise public health gain. Support for links to training, housing and employment services would further enhance wellbeing.
Perhaps more importantly we would argue that their preference for the ‘Dutch’ model (full decriminalisation of both parties) over the ‘Nordic model’ (making buying rather than selling sex a criminal offence, started in Sweden in 1999) is supported by an unbalanced portrayal of the evidence. While most feminists support decriminalisation of the sale of sex, feminists are divided between ‘liberals’ who argue that it is an individual’s right to sell sexual services and ‘radicals’ who take a more public health perspective and argue that buying sex is essentially abusive (not only for the prostitute, but also for unaware partners in committed relationships), and that any gains for some individuals are outweighed by the trauma and violence inflicted by taking part in selling sex. Sexual violence has been recognised by the World Health Organisation as a ‘serious public health and human rights problem,’(2) with individuals engaging in selling sex at greater risk, and suffering more violence (3,4) and repeat victimisation (5) than the general population.
The recent Home Affairs Committee report(6) provides a helpful summary of evidence, and has, so far, indicated it will recommend further moves towards the Dutch model rather than to criminalise the purchase of sex, as in Sweden. Grenfell’s editorial(1) highlights problems of the Nordic model, arguing against it rather than attempting to understand how to make it work. The implementation issues, encountered for example in Norway and Northern Ireland, when the Police have not been sufficiently involved or trained can certainly mean that the potential benefits in terms of increased access to services and reporting of violence are not realised. This can be compounded when underlying pervasive societal attitudes to people who sell sex, are not addressed, further perpetuating marginalisation.
In contrast Grenfell et al, don’t provide evidence about the problems of implementation of the Dutch model. For example in Germany where prostitution has increased and the so called ‘work’ is often carried out by vulnerable migrants; or in New Zealand where organised mega-brothels bring in high profits for owners/managers and create a desperate working environment for those selling sex.(7)
We suggest that there is a good public health rationale for using the Nordic model to reduce rather than legitimise prostitution, in order to reduce substance misuse, emotional distress and physical trauma. In Sweden, street prostitution reduced after 1999 and has stayed lower than in comparable countries, and public support for criminalisation of buying sex has stayed strong. We appreciate that this is work in progress, that there is much to learn, and that reliable quantitative evidence is hard to gather; but suggest that proper involvement of people who sell sex, the police, along with specialist outreach services to work alongside those still engaged as prostitutes, has the potential to make the Nordic model work and not only address concerns about spread of sexually transmitted disease but also provide the greatest good over time through a ‘harm reduction’ approach.
1. Grenfell P, Eastham J, Perry G, Platt L. Decriminalising sex work in the UK. BMJ 2016;354:i4459
3. Penfold C, Hunter G, Campbell, R et al. Tackling client violence in female street prostitution: Inter-agency working between outreach agencies and the police. Policing & Society. 2004; 14: 365-379.
4. Phipps, A. Violence against sex workers in the UK. In: McMillan, L, Lombard, N editors. Violence Against Women: Current theory and practice in domestic abuse, sexual violence and exploitation. (Research Highlights in Social Work Series), London: Jessica Kingsley Publishers; 2013. P.87-102.
5. Lea S, Callaghan L, Grafton I, et al. Attrition and rape case characteristics. A profile and comparison of female sex workers and non-sex workers. Journal of Interpersonal Violence. 2016; 31 (12): 2175-2195.
6. Prostitution. Interim report. Home Affairs Committee. 2016
Competing interests: No competing interests