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S20.3 The health impacts of sex work criminalization: a review of the evidence

Background Sex workers are at disproportionate risk of violence and sexual and emotional ill-health, harms that have been linked to criminalisation. Methods We synthesised evidence on the extent to which sex work laws and policing practices, affect sex workers’ safety, health and access to services, and the pathways through which these effects occur. We searched bibliographic databases for research with sex workers of all genders and terms relating to legislation, police and health. We operationalised criminalisation into categories of lawful or unlawful police repression of sex workers or their clients. We included quantitative studies measuring associations between policing and outcomes, and qualitative studies exploring related pathways. We conducted a meta-analysis to estimate the effect of experiencing physical/sexual violence, HIV/sexually transmitted infections (STI) and condomless sex, comparing individuals exposed and unexposed to repressive policing. We synthesised qualitative studies iteratively, inductively and thematically. Results We reviewed 40 quantitative and 94 qualitative studies. Meta analyses suggest that on average sex workers who had experienced repressive policing were at increased risk of sexual/physical violence from any party (OR=2.99 95% CI=1.96–4.5, n=5204), increased risk of HIV/STIs (OR=1.87, 95% CI=1.60–2.19, n=12506) and more likely to practice condomless sex (OR=1.42 95% CI=1.03–1.94, n=9447) compared to those who had not. The qualitative synthesis showed that criminalisation and repressive policing disrupted sex workers’ safety and risk reduction strategies and access to health services and justice, including where clients are criminalised. Criminalisation and regulatory frameworks exacerbated stigma, racial, economic and other inequalities. In decriminalised contexts, sex workers’ relationships with police have improved and they report being better able to refuse clients and insist on condom use. Conclusions The evidence shows the increased harms associated with sex work criminalisation—including laws and enforcement targeting the sale and purchase of sex, and sex work organisation. These demonstrably harmful sex work policies and laws must be reformed urgently if sex workers’ right to health is to be realised.