Continuing my series of posts on sex work, public health and radical feminism, this post will attempt to describe the public health issues surrounding modern sex work, and some common public health responses to it. For the most part I will be talking about developed nations; for a variety of reasons, different conditions pertain in the developing world, and the public health response there is more complex. But as we shall see, sex work in the modern era presents some unique problems, and the majority of modern responses to them have been based around pragmatism and public health, rather than moral hygiene concerns, and in this sense modern responses – even in poor and conservative countries like Bangladesh or Indonesia – can be very different to those we previously presented from 100 years ago.

Sex Work in the Modern Era: The Problem of HIV

Until the early 1980s it was looking like sex work as a public health problem had become largely irrelevant. With the discovery of effective tests and treatments for syphilis, gonorrhea and chlamydia the major public health problems “caused” by sex work seemed to be under control.  Of course, all of this changed when HIV entered the scene – in the early 1980s for the developed world, but much earlier in Africa – and suddenly sex workers were cast back in time, to the bad disease vectors of old, transmitting an incurable and deadly disease.

HIV is a classic example of how an infectious disease can survive in a community even though the majority of people are not engaged in the risk behavior that underlies its spread. Because it is asymptomatic for years, a small group of people can spread the disease through high risk behavior without even knowing they have it, and if this group of people is stigmatized and their reasons for getting or transmitting the disease make them subject to discrimination or public coercion, they are much, much less likely to get the voluntary screening that is needed to prevent the spread of the disease. In the absence of open coercion – which, in the case of sex workers, has been shown to be an ineffective public health measure for over a hundred years – some other tactic was needed to ensure that the disease did not become entrenched in this population.

In the early 1980s, HIV was a genuine emergency, and it’s instructive to look at what happened in Africa in order to see what happens if the disease goes unchecked in the general community for too long. In the absence of a treatment, and knowing that the disease is asymptomatic for years, the public health community in the developed world recognized that a new approach to sex work was going to be needed: there was no time for moral panics and placing our hopes in the ability of our moral leaders to force women out of the industry, and men out of purchasing sex. Instead, in the UK, Australia, Canada and much of Europe, a new approach was tested that was based on, essentially, bringing sex workers in from the cold.

The Modern Public Health Model for Sex Work

The modern public health response for sex work is built around multiple strategies, working at multiple levels of society and the health system, to ensure that traditional cultural, structural and economic barriers to seeking health care – and specifically, sexual health care – were removed rapidly. The main components of this model were:

  • Sex worker empowerment: Unlike the rest of the population, sex workers have absolutely no reason to want to have sex without a condom. There’s nothing in it for them, in general, and most of the reasons for condom-free sex in such an environment are structural. Where women are underpaid, under threat of violence, or unable to successfully negotiate with clients, condom-free sex happens. Where they are well paid, supported by management in protecting their health, and free from the threat of violence, they inevitably use condoms. This effect is even stronger if they are connected to a community of sex workers, so that everyone in the industry knows that in relenting on condom-only sex rules, they make everyone’s job harder. These gains are partly (and only partly) achieved through self-empowerment, the establishment of unions and representative organizations like the Scarlet Alliance, who can advocate for sex workers’ workplace safety inside and outside their workplace, and help sex workers to work together to ensure workplace safety. These were set up early in Australia, and have been very effective campaigners for the rights of workers
  • Legal changes: ultimately the best way to ensure the safety of women working in the industry is to legalize it, so that the industry shifts from the control of gangsters and thugs to a more standard business model. Legalizing (or decriminalizing) the industry enables government and health authorities to monitor conditions in brothels, to gain access rights, to vet the criminal histories of those who open brothels, and to ensure certain hygiene standards. It also removes the workers themselves from the oversight of the police, so that they go from criminals to civilians, and thus gain greater police protection. It also enables governments to set certain basic standards of criminal culpability on managers and workers alike. But most importantly, it enables sex workers to report crimes against them to the police, to openly employ security guards and receptionists, and to change the balance of power between worker and client – a key component in enabling the worker to enforce safe sex in the ultimately private portion of the business transaction.
  • Specialist services: it’s still common for doctors and nurses to be quite judgmental about promiscuity and sex work, so it’s important that if a worker is getting regular tests – monthly or quarterly, for example – or sex work-specific health care, she can do it in an environment that doesn’t discriminate against her on the basis of her work, and that understands the specific conditions of her work. While sex work is illegal (as it is in, e.g. Indonesia) it’s also important to have specialist services that have a “special” arrangement with the local police (these arrangements are actually quite realistic goals in a functioning civil society). Workers know that they can visit these services and have no fear of being harassed by or turned over to police. If a worker won’t visit a health service for fear of discrimination, mistreatment or legal trouble, she won’t get an HIV test. For much of the history of the HIV epidemic (until recently, in fact) there has been no personal benefit to the person with HIV of getting an early HIV test, since there was no treatment and it’s asymptomatic. Why go to the trouble of a test just to protect the broader community, if the broader community is telling you you are a worthless whore?
  • Practical law enforcement changes: Even where sex work is illegal, police can be convinced to look the other way, to treat sex workers leniently and with discretion, or to allow sex work under certain conditions. For example, in Sydney, Australia, there was a long-standing agreement between health and law enforcement officials that two streets in Kings Cross were acceptable locations for street-based sex work, even though it was illegal. There were also certain “safe houses” where women could take their clients, that the police only entered with good reason. Women working in these locations could be (reasonably) guaranteed safety from police harassment, and were working in highly visible and regularly-frequented zones – offering some protection against trouble. The police would also come to know these women, and would cooperate with local health services in finding them if they were needed, or getting them suitable emergency support. The first lesson of the era of HIV is that police do not need to be the enemies of people from whom they are supposedly protecting society.
  • Outreach and education: Having established these arrangements with police, health agencies can successfully run outreach programs to offer education, safer sex support, medical and drug treatment referrals, and basic social welfare advice. In the case of stable brothel-based workers this outreach can be minimal – a sex worker representative visiting a brothel once a month to check that all is going well, for example – but there is a sinister under-belly to the sex industry, of drug-addicted women and illegal migrant workers, who need a great deal more help.
  • Drug treatment services: This sinister underbelly involves women doing sex work to make money for drugs, and it’s well accepted that these women are at much greater risk of both violence and unsafe sexual activity than their non-addicted colleagues. They often work in the street, in extremely dangerous settings, under the influence of drugs, or in states of desperation. The best way to change these women’s lives is to get them into drug treatment, and this is also probably the best way to reduce the risk of the spread of HIV by these women – who are also at higher risk of getting HIV through injecting drug use. Again, for these women drug treatment services have to offer appropriate care that doesn’t drive them away due to their “vice.” It’s possible to imagine, for example, a “moral hygiene” focused drug treatment service that will not offer treatment to sex workers or “loose women.” The vicious cycle of drug abuse and sex work will ensure that these women will never get into treatment under such conditions. Fortunately, such drug treatment services largely don’t exist in any significant numbers anymore.
  • Practical public health interventions: Dispensing condoms, a weekly “ugly mug” bulletin that alerts street-based workers about potentially dangerous clients, sexual health clinics being open at times that suit women who work, outreach workers who understand the industry, courses on basic negotiation skills for women at work, are all practical public health interventions that may make a difference to how women work. But these interventions won’t work in isolation, and there’s limited evidence that they work in many settings: this is because the primary drivers of risk amongst sex workers are structural, and largely out of the control of the individual women in the industry.

The other, largely unresearched benefit of all of these services, in my opinion, is that they offer exit rights to women in the industry. It’s much, much harder to force women into sex work – either economically or through the vicious tools of the illegal immigrant contract – if the law enforcement, health system, and industry structure is designed to offer women essentially the same rights at work as they would have if they were working in a restaurant or an office. This ensures that only women who are capable of making a choice to work in the industry will stay in it long term, and these women will no doubt be much more capable of protecting their sexual health than women who don’t want to work in the industry and can’t get out. I’ll return to this aspect of the debate later, when I contrast this decriminalization model with the abolition model favoured by radical feminists. But first, let’s look at a success story under this model.

Australia: A Decriminalization Success Story

In 1984, when HIV reached Australia, sex work was still illegal and the industry was very much unregulated; but coincidentally with the arrival of HIV, in New South Wales (the most populous state) the Parliamentary Select Committee Enquiring into Prostitution had been commissioned, and recommended changes to the laws, including a movement towards decriminalization and the establishment of specialist services; the first (and only) such service was opened in 1986 at the Kirketon Road Centre. Sex worker representative bodies were established in 1987, and further legal changes happened slowly over the following 10 years. By the time I entered the public health field in 1995, it was well-established that sex workers were at lower risk of STIs than non-sex workers, that there had never been a case of HIV transmitted by a sex worker in Australia, and that sex workers were at higher risk of STIs from their non-commercial partners than their commercial partners. This was despite the fact that a large number of street-based workers were also injecting drug users, and at elevated risk of HIV. Subsequently, the law further improved as did the law enforcement agencies after the Woods Royal Commission into Police Corruption (approx. 1996); by the time I left Australia in 2006 it was virtually impossible to have commercial sex with a minor (something that was quite easy in 1986), and rape and violence against sex workers was taken very seriously by police, and prosecuted to the full extent of the law. It was also extremely unlikely that police would be able to get away with corrupt dealings with drug dealers or sex workers, due to legal changes to the treatment of these crimes and also due to a significant cultural change in the police force. Now, brothels in NSW are licensed by their relevant local council, brothel owners are vetted for criminal records, and brothels are subject to regular inspection. This gives councils sweeping powers to investigate and force the closure of suspected illegal brothels.

As a result, the public health and legal environment in New South Wales is vastly improved: for sex workers, their clients, the unsuspecting partners of those clients, migrant women who might have been tricked into appalling situations, and drug-using women working the streets. HIV remained confined to the drug using and homosexual populations, and the main drivers of diseases like chlamydia remained (much more intractable) young, high-risk non-sex working heterosexual people[1].

The Feminist Antecedents of Legal Reform

Much of the impetus for decriminalization of sex work came from the “second wave” of feminists: that is, women like Germaine Greer, Marilyn French, Simone de Beauvoir, and female parliamentarians of the 1970s. With the Second Wave of feminism came recognition that promiscuity could be acceptable, and a move to reduce the risks that women faced in taking control of their own sexuality: date rape, violence, and sexually transmitted infections (STIs) began to be seen as unreasonable risks for women to run in exploring a sexuality that, by the 80s, was generally recognized as their own to control. Part of the recognition of women’s right to control their own sexuality was their right to use it as they saw fit, and a body of political theory developed that saw prostitution as a type of work like any other, rather than a vice or evidence of a moral failing. Most of this feminist understanding of prostitution also drew on the keen understanding women like Marilyn French had of the very real economic and personal challenges facing women in the 1970s[2]: with work opportunities still very restricted, and many women having limited access to education, prostitution came to be understood not just in terms of its moral dimension, but as a form of empowerment within the restricted economic choices women faced in this time. Now, of course, the situation for young women is very different, but for a young woman aiming for independence in the 1970s, financial and employment opportunities were limited; sex work was seen by feminists as a legitimate response to these pressures, and moral judgment of it seen as representing more the failings of the system and the patriarchy than the moral failings of the individual women.

Of course, theory about decriminalization didn’t develop in isolation: at the same time the drug decriminalization movement had flirted with legalization and harm reduction had begun to be understood as a public health theory, and there was also a strong gay rights movement building in many countries. Second wave feminism was often focused on very pragmatic things, and it was only natural that from this brew they would develop a theory of the decriminalization of sex work, and it was a distinctly feminist campaign that culminated in the Prostitution Act in NSW (1979, I think) that led to the initial (4 year long) experiment in decriminalization. This was partially reversed in 1983, but remains a significant feminist victory and marks a clear break from the moral panic of previous eras when faced with sex workers and public health. Of course other countries were trying the same things, and the growth of sex worker representative movements in the 1980s also guaranteed that the combined feminist/public health goals of decriminalization would spread around the world. Perhaps this stuff wouldn’t have happened so fast if not for the pressures of the early HIV era; but regardless of the public health pressures, the role of feminists in establishing the groundwork and theory of decriminalization needs to be recognized.

In the next post, I’ll try to show how radical feminists view sex work and promiscuity, in contrast to the second wave. You’ve made it this far – stick around!

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fn1: Some readers may be confused as to why I care about chlamydia, which many people think is harmless, like a kind of common cold of the genitals. In fact, chlamydia is a scourge: it is often asymptomatic, and causes most men no significant harm; but if undetected in women it can lead to Pelvic Inflammatory Disease, which is very nasty and can cause infertility or increased risk of ectopic pregnancy. Ectopic pregnancy is a devastating condition for an expecting mother (it invariably leads to miscarriage) and can be fatal if undetected. Amongst all the public health problems facing the world, chlamydia is no doubt far from the worst (or even very bad) but it’s still a nasty, unnecessary little blighter and the sooner we can get rid of it the better.

fn2: It can be bitter stuff, but I strongly recommend reading Marilyn French if you want to get a clear, powerful description of the very different circumstances facing women in love in the 60s and 70s compared to now. It’s well written, tough and uncompromising, and helps to give a sense of the passions that drove this wave of feminism – and how far we have come.