Intended for healthcare professionals

Feature Public Health

Sex workers’ health: international evidence on the law’s impact

BMJ 2019; 364 doi: (Published 24 January 2019) Cite this as: BMJ 2019;364:l343

Linked feature

Better health for sex workers: which legal model causes least harm?

  1. Sally Howard, journalist
  1. London, UK
  1. sal{at}

The authors of a new systematic review say that criminalising sex workers is bad for their health and that full decriminalisation is the healthiest option. Others maintain that people buying sex should be prosecuted. Sally Howard reports

Criminalisation of sex work is linked to “extensive harms” among sex workers, concludes a systematic review of the evidence in 33 countries from 1990 to 2018. Its authors say that the review, published in PLOS Medicine,1 is the first to consider sex workers’ health and safety and their access to health and social services.

The research is timely because of global political interest in new legal models of full decriminalisation and of criminalising people who pay for sex, said coauthors Lucy Platt and Pippa Grenfell of the London School of Hygiene and Tropical Medicine, launching the research in London in December. For example, Australia has seen calls for a nationwide rollout of the decriminalisation model introduced in New South Wales in 1995, and Spain’s prime minister has made criminalising sex buyers a flagship policy of his first term.

Full decriminalisation

As used in New Zealand since 2003 (box), full decriminalisation should be the preferred legal model everywhere, Platt argued, as it had led to sex workers being better able to refuse clients and to insist on condom use.

The researchers wrote, “Opponents of decriminalisation of sex work often voice concerns that decriminalisation normalises violence and gender inequalities, but what is clear from our review is that criminalisation does just this by restricting sex workers’ access to justice and reinforcing the marginalisation of already marginalised women and sexual and gender minorities.

“The recognition of sex work as an occupation is an important step towards conferring social, labour, and civil rights on all sex workers.”

But Lynne Callaghan, a senior research fellow at Plymouth University who works with sex workers using health services and supports criminalising sex buyers, urges caution. She said, “The review highlights the current dearth of evidence of the potential health and social impacts of criminalising or decriminalising the purchase and/or selling of sex. We should not be making policy decisions on the basis of this review.”

Sexual and physical violence

Sex workers who were criminalised were found to be three times as likely as other sex workers to experience sexual or physical violence (odds ratio 2.99 (95% confidence interval 1.96 to 4.57)), twice as likely to contract HIV or another sexually transmitted infection (1.87 (1.60 to 2.19)), and one and a half times as likely to report having condomless sex with a client (1.42 (1.03 to 1.94)).

Fear of police and an increased police presence were associated with sex workers avoiding healthcare settings,2 presenting less often for HIV testing, and having less access to HIV prevention.

The researchers’ mixed methods review meta-analysed 40 quantitative and 94 qualitative public health and social science studies of male, female, and trans sex workers. The quantitative findings, said the authors, were limited by diverse data, an absence of studies on male sex workers, and a lack of evidence relating to healthcare access beyond testing for HIV or sexually transmitted infections.

In some contexts, arresting sex workers was found to be associated with increased odds of forced attendance at sexual health clinics or testing for HIV.

The review found many negative effects on sex workers’ access to general and sexual healthcare under criminalisation. Police crackdowns on venues and outdoor areas where sex work occurs can displace sex workers, restricting their access to outreach services. Laws against soliciting and communication in public spaces lead to sex workers rushing client screening and negotiations. And laws against brothel keeping reduce condom use and prevent sex workers from working together for safety.

Failing the majority

Studies in Mexico, Turkey, and the US state of Nevada show that licensing sex work in some form enables access to safer conditions and healthcare for some sex workers but excludes the majority, including the most marginalised.

Also speaking at the London research launch was Raven Bowen, who leads a UK sex worker information and safety charity, National Ugly Mugs (NUM). She said that sex workers too often experience stigma in healthcare settings, and “NUM’s data show that many sex workers won’t access health services without a guarantee of non-judgmental support.”

Bowen argued that this exclusion can be tackled only through legal models prioritising sex workers’ civil and human rights. Decriminalisation should be combined with targeted laws against hate crime, she told The BMJ, to tackle stigma and compel healthcare services to treat sex workers like other patients.

The right to health

Reform of harmful laws and policies on sex work is urgently needed if sex workers’ rights to health are to be realised, said Platt. Alongside legal and institutional reforms she highlighted a global need for funding of specialist services, and services led by sex workers, to tackle the diverse social and healthcare needs of people who sell sex.

A UK Home Office spokesperson said, “There is no unequivocal evidence that shows a change in the law for prostitution or paying for sex would protect vulnerable people rather than exposing them to further harm.

“This is why we are funding research into the scale and nature of prostitution in England and Wales. We are committed to tackling the harm and exploitation associated with sex work and believe that anyone who seeks routes out should be supported to do so.”

The Home Office has awarded the University of Bristol £150 000 (€171 000; $194 000) for the research and expects its report this spring.4

Richard Byng, a GP and academic who supports criminalising the purchase of sex, told The BMJ, “The paper shows that criminalising those who sell sex is likely to adversely affect health and wellbeing. But the study has not included sufficient data from those who have exited the traumatic effects of prostitution, and it in no way has sufficient data to show, as the authors assert, that socially progressive models aiming to reduce demand from buyers are harmful to overall health.”

Models of criminalising sex work vary worldwide, including:

  • Full criminalisation, including selling and buying sex and associated activities, as in South Africa and the United Arab Emirates

  • Criminalisation of buying sex, as in Sweden, Norway, and France

  • Regulation through licensing, as in the Netherlands, Germany, and the US state of Nevada

  • Full decriminalisation, as in New Zealand and Denmark (in the latter, third party activities such as coercion and procuring remain illegal), and

  • Criminalisation of sex work through associated activities such as brothel keeping, kerb crawling, and advertising of sexual services, as in England, Wales, and India.3


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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