Sex workers’ health: international evidence on the law’s impactBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l343 (Published 24 January 2019) Cite this as: BMJ 2019;364:l343
All rapid responses
In Leeds, a ‘Managed Approach’ model has been introduced in a designated non-residential area of the city to meet the specific issues and challenges of street-based sex work. This follows a range of enforcement led-initiatives undertaken for over a decade, which in the long-term did not reduce on-street sex work, did not provide meaningful support to sex workers nor decrease the impact of street-based sex work on the local community. The Managed Approach was put in place in response to these issues. As part of a partnership approach, this includes working with third sector organisations. Specific operational rules are in place as part of the Managed Approach which mean in designated hours, a strategic approach is taken in terms of how enforcement is managed on soliciting or kerb crawling. The area continues to be policed through the designated hours and laws are enforced relating to any acts of indecency, crime or anti-social behaviour.
The Managed Approach in Leeds is controversial and not without criticism. However, those working within sexual health and third sector organisations that support these women (Basis, Joanna Project and wider partners such as housing, drug treatment etc.) feel that this set up gives women the ability to be free from the fear of arrest, ability to negotiate with their clients, have a better relationships with the Police in order to report crimes and have access to sexual health services including sexually transmitted infections (STI) testing and treatment, vaccinations, and contraception, all of which adds to their safety and autonomy.
The Managed Approach allows organisations to offer support and services to women on the streets, to introduce themselves and provide information on the services available. This has enabled the sexual health services to access and build rapport and trust with sex workers (SWs), therefore enabling them to access screening and/or reliable contraception.
In the 12-month period of 2017 Leeds Sexual Health had 373 contacts with 166 SWs via their outreach programme with Basis and Joanna Project. 57% of these women had never accessed the sexual health service previously, therefore evidenced as a hidden population. During this time the number of women on a non-barrier method of contraception increased from 39% to 57%. Amongst these women a full range of STIs were detected and treated, 38 in total.
The Managed Approach policy was introduced in 1st October 2014 and so far there is evidence of its benefits from a service perspective. An increased access to outreach services and higher take up of social and health care interventions has been shown as there has been a 110% increase in interactions between street working women and support services. Additionally, reports that SWs are less fearful of arrest minimise the fear of arrest from the by police and therefore more likely to report are evidenced as reporting of crime with full details to the Police increased from 7% in 2013 to 52% in 2015 and in 2018 had maintained at that level. 
Whilst this approach can be seen as controversial, sex work has been around longer than any of us reading this, and will continue to be for the foreseeable future. By driving it underground we are making these women (and men) invisible, reducing their access to health services and not facilitating help with potential exit strategies. Our experience in Leeds would confirm that decriminalisation of sex work is the safest option to enable sex workers to access health and support services.
1 Crow M. Oral presentation. Contraception Use in Sex Workers in a Major UK City: The Impact of Outreach Services. Faculty of Sexual and Reproductive Health Annual Scientific Meeting, 18th May 2018, Edgbaston Stadium, Birmingham.
Competing interests: No competing interests
Will be bmj permit me to hark back?
It was in 1969-70, that a fellow student at the Royal Institute of Public Health and Hygiene in Portland Place, London W1 wrote his DPH dissertation on public health aspects of prostitution. He had studied the subject in his local authority. As I recall it, his name was Dr Peach. The Institute has disappeared. The dissertation might be in the cellars of whichever body took over the properties of the said Institute.
Anybody interested might care to investigate? It may even be in the British Library?
In those days, the term “sex worker “ had not been invented. The word prostitute has of course been in use since times immemorial. The public health doctors did not, as far as I knew, indulge in sneering at the prostitutes,. Male prostitutes were less common. At least less often talked about.
Came the 1980s and HIV. It was then that male prostitution received serious attention.
And when I started propagating the use of condoms, the local newspaper refused to print the word CONDOM. An activist in the local gay scene came to see me and agreed gladly to set up access points for free condom supplies.
I was able to correspond with the organiser of the English Collective of Prostitutes. Yes, it did exist and did work for the safety, health and welfare of the prostitutes in London.
My work in this sphere did cause good humoured jokes. Amongst doctors in the area.
Modern doctors may not be aware thst in those days of long ago, every local authority had notices in local
Public toilets, displaying the opening times of the Venereal Disease Clinics. Pre-1948 these clinics were run by the local health authorities, the medical officer of health being responsible. After 1948 the management was taken over by the Regional Hospital Boards,. Even when the local health authorities managed the clinics there were no territorial restrictions and you did NOT have to give your real name , your real address nor any identifying information. Of course the mariners went to any clinic they fancied.
I leave it now to the present day public health organisers to tell us how they manage the services.
Competing interests: No competing interests
It was fantastic to see your recent feature on Protecting sex workers’ health: evidence on the law’s impact by Sally Howard (1). Poor statistics on sex workers can make research into health of this marginalized and transient group extremely difficult (2), resulting in little progression and development of services. It was interesting that the report discussed how legal frameworks have an impact on Sex Workers health but I want to draw attention to how in the UK, along with the barrier of stigma and the law, Sex Workers are facing greater restrictions to their access to healthcare. While studying at Imperial College London last year I conducted an audit into the number and service provision for sex workers in London, which was discussed in a BMJ blog (3). I found that over the past 2 decades services have dramatically reduced in number and there has also been a decline in services providing comprehensive social and wellbeing care. I believe that this highlights that even if there were dramatic changes in the legal framework surrounding sex work, sex workers would still struggle to access timely and appropriate services.
During informal discussions I conducted with service providers, funding was repeatedly cited for the cause of reduction in services. Funding cuts having detrimental effects on sexual health services has been widely acknowledged with White et al. (2017) reporting a 5-10% annual reduction in sexual health provision across the UK (4,5). The British Association for Sexual Health and HIV has even launched a petition to reverse these damaging cuts to sexual health care (6). Austerity has also been reported to have increased the number of women turning to sex work (7). This means that austerity in the UK is both intensifying the issue along with reducing access to healthcare.
I believe that we need to simultaneously address how austerity measures and the resultant reductions in funding are affecting health as well as changing legal frameworks to protect the most vulnerable. These need to be addressed together to truly improve health and wellbeing among Sex Workers and other marginalised communities.
Amelia Davies (4th Year Cardiff University Medical Student)
1. Howard S. Protecting sex workers’ health: evidence on the law’s impact. BMJ. 2019;365(8294):10–1.
2. Ward H, Day S. What happens to women who sell sex? Report of a unique occupational cohort. Sex Transm Infect. 2006;82(5):413–7.
3. Davies M. Services for Sex Workers in London [Internet]. The Journal of Sex Research. 2018 [cited 2019 Apr 6]. Available from: https://blogs.bmj.com/bmjsrh/2018/08/30/services-for-sex-workers-in-london/
4. White C. Sexual health services on the brink. BMJ. 2017;359(November):j5395.
5. Robertson R. What do cuts in sexual health services mean for patients? [Internet]. 2017. Available from: https://www.kingsfund.org.uk/blog/2017/03/what-do-cuts-sexual-health-ser...
6. British Association for Sexual Health and HIV. Save our sexual health services - Public Petition | British Association for Sexual Health and HIV [Internet]. 2018 [cited 2018 May 8]. Available from: https://www.bashh.org/news/save-our-sexual-health-services-public-petition/
7. Howard S. Better health for sex workers: which legal model causes least harm? BMJ [Internet]. 2018 Jun 20 [cited 2019 Apr 6];361:k2609. Available from: https://www.bmj.com/content/361/bmj.k2609
Competing interests: No competing interests