Credible evidence shows that, where sex workers are able to negotiate safer sex, HIV and other risks can be better managed and greatly reduced. A systematic review found that sex workers subjected to arrests, prison or displacement from places of work had a three times higher chance of experiencing sexual or physical violence and were twice as likely to have HIV and/or other sexually transmitted infections (Platt et al, 2018).
The UK has an estimated 72 800 sex workers, around 90% of whom are women (House of Commons Home Affairs Committee, 2016). UK laws currently make it a criminal offense for sex workers to work together for safety, which means they are deterred from reporting any violence for fear of arrest. Having a criminal record for offences relating to their work makes it harder to find other employment.
Sex workers can present nurses with distinctive challenges. Fear of judgement and criminalisation, language barriers, unstable immigration status and a disordered manner of living can all act as a barrier to accessing health care. Those who work on the street have a higher risk of complicated health problems and are more likely to present with STIs, drug/alcohol dependency and mental-health needs.
The impact of criminalisation on sex workers' health has been highlighted in the Lancet: a study found that full decriminalisation of sex work could reduce new HIV transmissions by up to 46% globally over a decade (Shannon et al, 2015). Data from a range of countries has shown that sex workers who worried about getting arrested were up to four times more likely to accept more money for engaging in unprotected sex (Platt et al, 2018); criminalisation decreased their power to stand up to clients.
Countries that have decriminalised sex work have higher rates of condom use (Platt et al, 2018) and sex workers are able to organise community-based health support. Decriminalisation removes fear of arrest or prosecution, making it possible for sex workers to report crimes such as assault, theft, abuse or the exploitation of minors.
Decriminalisation is supported by the Global Alliance Against Traffic in Women, who have argued that decriminalisation of sex work would positively impact the fight against human trafficking (Global Alliance Against Traffic in Women, 2013). Sex workers can be allies in the fight against trafficking and exploitation; in environments where they do not have to fear criminalisation they can report incidents to police and other agencies. In New Zealand, where decriminalisation is in place, there has been no evidence to suggest the size of the sex industry has increased, nor that trafficking into sex work is any higher than in any other country.
There have been proposals for a so-called Nordic model, which criminalises the buyer not the seller, arguing that this would reduce demand. However, this model is built on the assumption that sex work exists because of demand—the reality is most sex workers enter the industry for socioeconomic reasons, which will be unchanged by any drop in demand (Platt et al, 2018). When half a transaction is illegal, it pushes the whole transaction into the dark. Research in Sweden and Canada has also shown that criminalising clients did not improve sex workers' safety or access to services and, in some cases, showed a detrimental impact (Platt et al, 2018). Violence against sex workers rose by almost 50% in Ireland since the introduction of a sex purchase law and in France by 42%, where 38% of sex workers reported they were finding it harder to insist on condom use (Médecins Du Monde, 2019). By implementing a Nordic model the Government would be focusing national policy on a moralistic ideology that is at odds with the evidence-based practice promoted by the nursing profession.
At the 2005 Royal College of Nursing Congress, nurses voted 4–1 to back the decriminalisation of sex work. In 2009, delegates voted by 355 votes to 83 in favour of decriminalisation. This is not just a health issue; it's an issue of human rights. As nurses, I believe we should always be suspicious of those who want to give governments more control over women's bodies and should be lending our voice to marginalised groups who need our support.