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
- Pippa Grenfell, research fellow in public health sociology1,
- Janet Eastham, sex worker activist2,
- Georgina Perry, service manager3,
- Lucy Platt, senior lecturer in public health epidemiology1
- 1Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine,
- London WC1H 9SH, UK
- 2Sex Worker Open University, UK ( )
- 3Open Doors, Homerton Hospital University NHS Foundation Trust, St Leonard’s site, London N1 5LZ, UK
- Correspondence to
Last month the UK House of Commons Home Affairs Committee called for street soliciting and the sharing of premises by sex workers to be decriminalised, and for associated convictions and cautions to be deleted.1 The recommendations have been hailed as a victory for sex workers’ rights and for evidence over ideology.2 However, the public health gains that could be achieved through this progressive approach will be undermined by ongoing cuts to specialist health and support services for sex workers, amid a government led ideological realignment of resources.
The select committee’s recommendations have the potential to redress extensive harms that sex workers have experienced as a criminalised population, particularly if they are coupled with measures to remove penalties against clients. Enabling sex workers to share premises would increase safety at work.3 Removing penalties for soliciting and kerb crawling would relieve economic pressure, provide more time to negotiate services and screen out potentially violent clients, and lessen the need to work in isolated areas4—all factors linked to an increased risk of violence and sexual ill health.5 Deleting sex workers’ police records would reduce barriers to accessing housing and, for those who wish to leave sex work, alternative employment. Crucially, these legislative changes are likely to increase trust between sex workers and police and improve access to outreach services.4
Role of specialist services
Specialist services for sex workers play a vital role in meeting the diverse needs of this marginalised and dynamic group. In the UK these services have controlled outbreaks of HIV, syphilis, and tuberculosis among sex workers,6 and outreach programmes have more than halved the risk of contracting sexually transmitted infections.7 Specialist services also work with local agencies to provide integrated care and case management. They support sex workers who have experienced sexual violence; help them deal with drug and alcohol use, mental health issues, and housing needs and avoid criminalisation; and employ multilingual outreach workers in settings where many sex workers are migrants.
This joined-up approach reflects best practice by combining consideration of the policy environment, community level interventions, and tailored individual responses.5 Specialist services particularly benefit the most marginalised sex workers, such as migrants and those who are homeless, use drugs, or work outdoors, connecting them to mainstream health and social care. However, given the stigmatised nature of the industry, all sex workers could benefit from such services. Some sex workers are not registered with primary care doctors, and those who are may be reluctant to disclose their profession out of fears over confidentiality and judgment.8
A growing number of specialist services across the UK have faced substantial funding cuts in recent years, mirroring wider cost savings and shifts in commissioning environments.9 The withdrawal of local government funding for outreach and key staff positions in London and other UK cities threatens to seriously limit capacity to provide specialist, integrated care to sex workers (personal communication, Rosie Campbell, board member and joint academic representative, National Ugly Mugs). Planned budget cuts of over 40% to the Open Doors service for sex workers in east London, for example, will reduce it to a primarily clinic based service, limiting outreach to street based settings, even though most sex workers work indoors, and compromising case management opportunities. Concurrent shifts in how such services are commissioned—increasingly through local authorities’ violence against women and drugs and community safety strategies rather than public health—increase pressure to prioritise “exiting” (supporting sex workers to stop sex work) over evidence based public health approaches. In parts of London and other UK cities the police are already implementing penalties against people who sell and purchase sex,10 reflecting full criminalisation in the United States, a model rejected outright by the Home Affairs Committee.1
As its inquiry continues, the committee will consider the “sex buyer law” that criminalises the purchase of sex, introduced in Sweden and five other countries, and full decriminalisation (of buyers and sellers), implemented in New Zealand. Evidence from Sweden and Canada shows that criminalising their clients reinforces sex workers’ exposure to violence and marginalisation, because of rushed negotiations, decreased reports of violence to the police and less priority on public health interventions.11 12 In New Zealand sex workers now report being more able to refuse clients and to insist on condom use, amid better relations with managers and the police.13
We urge the committee to consider this international evidence and emerging data from the UK in recommending a broader legal framework, but legislative change alone is not enough. Decriminalisation is likely to be a crucial step towards improving sex workers’ health and safety. But if we are to prevent avoidable harms and disastrous long term costs, it is vital that specialist services for sex workers, including outreach and case management, are also protected through adequate public health government funding.
We would like to thank Alex Feis-Bryce (chief executive officer, National Ugly Mugs), Rosie Campbell (research associate, Leicester University), and the peer reviewers for providing valuable information and comments.
PG and LP contributed equally to this editorial. LP, PG, and GP developed the initial proposal for the editorial. LP and PG prepared the initial draft, and JE provided substantive information, written input, and comments. All authors contributed to and approved the final manuscript.
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare: PG and LP hold research grants from Open Society Foundations and the National Institute for Health Research related to this topic. JE is a sex worker activist member of the Sex Worker Open University (SWOU). GP is service manager at Open Doors.
Provenance and peer review: Commissioned, peer reviewed.