Globally, sex workers (those who trade sexual services for money, goods, food, shelter, housing, or other resources) have been identified as a key group in the fight against HIV. But they face many obstacles when gaining access to health and social services. In the U.S., where most sex work is illegal and carries high criminal penalties, fear of prosecution is a barrier to care for sex workers. They can also face strong social stigma and discrimination in social service and medical settings.
Around the world, in places where there are few legal protections, sex workers experience physical violence and coercion while working, making them more vulnerable to HIV. In contrast, when there are greater protections, sex workers are more likely to be able to obtain health services and to practice safer sex. In many U.S. cities, the possession of condoms has been used as a means to intimidate, arrest, and detain sex workers on prostitution charges, undermining the health and safety of sex workers. This tactic also affects those profiled as sex workers, such as transgender women and people who don't conform to gender norms
Stigma in Health Care
The degree to which sex work is criminalized often dictates sex workers' ability to negotiate and manage their work. In places where certain forms of sex work are decriminalized, such as New South Wales, Australia, research has shown that sex workers have greater access to health and social services and are less likely to be victims of violence or coercion. But in the U.S., the criminalization of many forms of sex work limits the ability to access health and social services.
Over the past decade, several studies have focused on stigma as a barrier to health care access for people in the sex trade, particularly their difficulty in disclosing about sex work to a health care provider. Sex workers are unlikely to discuss this with a health care provider, friends, or family, often due to negative experiences or fears of disapproval, and this can have a profound impact on their physical or mental health. Nonjudgmental and affirming health care for sex workers results in more positive health outcomes and improves their ability to manage stigma.
Many health care providers have only limited training in how to work with such a sensitive population or do not know how to deal with sex-related issues in general. Many providers either know little about sex workers -- because no one has ever disclosed to them -- or are afraid to ask for fear of appearing ill-informed. Sex workers who do disclose are often met with either misinformation or mistreatment. A study published in 2010 surveyed over 2,200 medical students and found that over 53% felt they had not received enough training in medical school to address their patients' sexual concerns. These students were also more likely to report not being comfortable talking to patients about sexual health, drawing a correlation between education and comfort regarding sexual issues.
This lack of formal training, coupled with limited comfort speaking about sexuality, means health care professionals will base their care upon preconceived notions about sex workers, often the result of biased media coverage or harmful stereotypes. These notions can be highly problematic, filled with misunderstandings of sex workers' lives.
What Works for Sex Workers
We need to support more effective HIV interventions in the U.S., similar to the strategies used in some other countries. Efforts to fight HIV among sex workers have been successful in Bangladesh, the Philippines, India, the Dominican Republic, Nicaragua, Thailand, South Africa, Cote d'Ivoire, Benin, and Ukraine. These programs offer substantial evidence that targeted, comprehensive HIV prevention programs are effective in reducing HIV transmission and in making sex work safer. They make testing and treatment services readily available, provide condoms and promote their use, and utilize interventions that include outreach, peer education, and community empowerment.
Some HIV prevention efforts have focused on labor empowerment, such as the development of workers' cooperatives. These cooperatives support the connection between positive labor conditions and positive health outcomes for sex workers. Research supports interventions that use a community empowerment model. But the criminalized nature of sex work in the U.S. keeps many from supporting these strategies among sex workers, for fear of being denied funding and considered supportive of prostitution.
Using sex workers' input in decisions regarding their health care is a recurring theme in successful HIV interventions globally. Research also suggests that peer education works best for sex workers when it is paired with direct services (to address needs beyond prevention) and community empowerment (to make programming sustainable and relevant). Peer-led programs can adapt health messages to fit the community's needs and build relationships with hard-to-reach groups. They have been linked to increases in knowledge about HIV, as well as reduction of risk behaviors.
Fighting HIV With, Not Against, Sex Workers
The National HIV/AIDS Strategy emphasizes prevention services that limit the spread of HIV from those already infected. Federal funds use a "seek, test, treat, retain" approach for finding people with HIV who do not know they are infected and linking them to care. But what does this strategy look like when applied to sex workers?
For sex workers in the U.S., the notion of being sought for HIV testing may be frightening, especially considering that sex workers have long been forced into medical and social programs, rather than being willing participants. In U.S. prisons, sex workers have faced mandatory testing, and those who test positive can face extreme isolation from other inmates. Within public health settings, there exist deep historical misconceptions of sex workers as vectors of disease and vice. The historical association of disease and deviance with sex work has stigmatized sex workers as inherently "dirty" and in need of social correction.
For over a century, these misperceptions have led to many attempts to "reform" or aid sex workers, isolating them and creating a threat to public health. At the beginning of the AIDS epidemic, the panic-driven efforts of lawmakers led to proposals such as California Bill 2319, which would have required mandatory HIV testing for sex workers and felony charges for prostitution-related offenses. In an effort to both identify and profile sex workers, this bill would have set a precedent for testing any person even suspected of prostitution.
Globally, sex workers in Greece and Malawi have faced forced HIV testing sanctioned by the state. In 2012, Greek police began targeting sex workers, forcing them to undergo HIV testing. They also posted the names and photographs of those who tested HIV positive on official police websites. These actions were condemned by the U.N. Programme on AIDS, Amnesty International, the Global Network of Sex Work Projects, and the Global Network of People Living with HIV/AIDS. In Malawi, 14 sex workers decided to sue the government and challenge the constitutionality of forced HIV testing. This legal case was among the first of its kind to make its way through the courts.
The Anti-Prostitution Pledge
Though the U.S. government has acknowledged the need to engage sex workers and protect their rights as important pieces of HIV prevention programs, laws that criminalize sex work continue to create conditions that hinder these very programs. Fortunately, one such barrier -- the so-called "anti-prostitution pledge" -- no longer stands in the way. The anti-prostitution pledge required organizations seeking PEPFAR (President's Emergency Plan for AIDS Relief) funds to have a policy opposing prostitution. The pledge limited or eliminated partnerships with sex workers and the organizations that support them, as well as forced some organizations to conceal their work with sex workers or refrain from publishing important efforts with sex workers.
According to the U.N., less than 1% of global funding to prevent HIV is spent on sex workers, despite high infection rates. The pledge not only financially limited the services available to sex workers, it also undermined approaches in health and social services that were based on human rights. And it stood in sharp contrast to successful interventions outside of the U.S. that provided better health outcomes by including sex workers, such as VAMP, the sex worker-led health project of SANGRAM in India.
Since the pledge not only prohibited the use of any government money to "promote or advocate the legalization or practice of prostitution" but also required that almost all recipients of funds refrain from any speech the government deemed "inconsistent with" the policy, the provision violated First Amendment rights. Fortunately, the U.S. Supreme Court recently declared the pledge unconstitutional.
How the Supreme Court's decision affects HIV efforts in the U.S. remains to be seen. The unconstitutionality of the pledge in the U.S. does not affect its use internationally, where the vast majority of PEPFAR funds are spent. Additionally, the portion of the pledge that states that no funds "may be used to promote or advocate the legalization or practice of prostitution" remains. In the past, this prohibition has been used by USAID to decide whether legal assistance for sex workers can be seen as "promoting" sex work, discouraging organizations from providing legal help to address sex worker abuse and exploitation.
The U.N., WHO, Human Rights Watch, and other organizations worldwide have publicly declared the decriminalization of sex work as being in the interest of human rights. But it's uncertain whether the Supreme Court ruling that the pledge is unconstitutional will bring us any closer to ending the criminalization of sex work in the U.S. -- the primary barrier to health and well-being for sex workers.
In global efforts against HIV, countries that have made significant investments in programs for sex workers have reduced or stabilized their rates of HIV infection, demonstrating that these interventions are effective tools. Within the U.S., however, punitive laws, policing based on profiling, and discrimination remain persistent barriers to care for sex workers at risk of HIV, fueling the epidemic.
Working to end the stigma and discrimination experienced by sex workers, particularly in public health settings, is a critical component of fighting the HIV epidemic. The success of public health policy depends upon the cooperation of those affected. Though sex workers continue to be at high risk for HIV, reaching and engaging them can be complicated. Unfortunately, funding for programs for sex workers continues to decrease or be limited by federal restrictions. With the Supreme Court's ruling on the unconstitutionality of the anti-prostitution pledge, there is hope that research will now emerge to support such interventions in the U.S., increasing interest in serving this vital population in the fight against HIV.
Despite the limitations we have faced, community-led efforts to empower sex workers continue to grow. Saint James Infirmary, the first and only clinic for sex workers in San Francisco, recently celebrated 20 years of creating a "community space for all sex workers, where safety and health care was regarded with the utmost importance." In New York City, Persist Health Project (Providing Education and Resources in Support of Individuals in the Sex Trade) was founded in 2012 by a group of current and former sex workers, trafficking survivors, and allies, who provide care coordination and health education for people in the sex trade. Hook Online, an online resource for men in the sex trade, and the recently launched NSWP+, a program of the Network of Sex Worker Projects, offer online global opportunities for sex workers to engage with each other and with affirming support systems.
Recently, sex workers and allied organizations in New York and California have advocated for bills that would make it illegal to arrest sex workers or people profiled as sex workers for carrying condoms. The effort was supported by reports from the PROS Network (Providers and Resources Offering Services to sex workers) and Human Rights Watch. Working with anti-trafficking organizations, LGBT anti-violence groups, and youth organizers, sex workers were able to pass A2736, the "No Condoms as Evidence" bill in the New York State Assembly. Though there is still work to be done to pass the bill in the NYS Senate, and to ensure that sex workers are genuine partners in efforts against HIV, these steps forward are encouraging in the fight for human rights and access to health care for sex workers in the U.S.
Sarah Elspeth Patterson is the Co-Founder and Care Coordinator of Persist Health Project.