Understanding sexual violence in sex working populations-Law, legal consciousness and legal practice in four countries (2021-2023): Study Protocol v2.5.

BACKGROUND: Globally, the most important human rights and public health issue that sex workers face is their experience of high levels of violence (Kinnell, 2006, Kinnell, 2008, Alexander, 1999). Deering's systematic review estimated levels of sexual violence in sex working populations as being between 14% and 54% (Deering et al, 2014). AIMS: This international, robust mixed methods study will explore the frequency of sexual violence against sex workers, barriers in criminal justice and the legal consciousness of sex workers regarding their rights and consent. The hypothesis to be tested is that the safety of sex workers from sexual violence is mediated by the differing legal contexts of sex work environments. We will compare experiences across research sites in the context of legalisation (Nevada USA), client criminalisation (Northern Ireland), decriminalisation (New Zealand) and partial criminalisation (England, Scotland and Wales) [henceforth ESW]. METHODS: An international survey (n = 1,000) will be translated into several languages, to disaggregate experiences by demographic categories (gender, ethnicity, sexual orientation) and sex work sector (including online, street-based and brothels). Interviews (n = 100) with sex workers, police, prosecutors and service providers will be thematically analysed to explore legal consciousness, why the patterns occur and contextualise the statistical findings. These data will be supplemented with comparative legislative, policy and case analysis. Research study data will be used to compare the social factors and legal norms shaping sex workers experiences of sexual violence, justice and support interventions. Recommendations for a 'best practice' review of legal improvements and support interventions will be produced following completion of the study. Given the sensitive nature of the research, robust ethical and data protection mechanisms are in place. The research has ethical approval from each research site, an Advisory Board and trained, paid peer researchers to assist with data gathering, analysis and dissemination. The study will report findings in 2023/2024.

Informal settlements, Covid-19 and sex workers in Kenya.

This paper highlights the challenges faced by female sex workers living and working in the urban informal settlements in Nairobi, Kenya, during the Covid-19 outbreak and the aftermath of the pandemic. Using data collected through phone interviews during the immediate crisis, we document the experiences of urban poor sex workers, illustrating the acute problems they faced, including precarious housing with the reality of eviction and demolition. The paper highlights the ramifications of the Covid-19 crisis for the sex industry and predominantly women working within this informal, illegal economy. Through our empirical data we illustrate how the nature of selling sex has changed for sex workers in this context, increasing risks of violence including police abuses. We argue that examining the Covid-19 crisis through the lens of one the most marginalised populations graphically highlights how the pandemic has and will continue to deepen pre-existing structural urban inequalities and worsen public health outcomes among the urban poor. Sex worker communities are often located at the intersections of structural inequalities of gender, class, race and nation and the socio-spatial fragmentations of how they live make them some of the most vulnerable in society. We close with comments in relation to sexual citizenship, exclusionary state practices and the feminisation of urban poverty.

Prevention of modern slavery within sex work: Study protocol of a mixed methods project looking at the role of adult services websites.

BACKGROUND: The core challenge this study addressed is that Adult Services Websites (ASWs) are an extensive and pervasive feature of the digital world that facilitate the advertising, negotiation and purchase of sexual services yet are also considered to be harbourers of sexual exploitation, modern slavery and human trafficking (MSHT) Giommoni L. et al. 2021, Milivojevic S. et al. 2020, Sanders, T., et al. 2018. Whilst awareness of cases of internet facilitated MSHT has entered the public and policy domain, little is known about the role and responsibilities of ASWs in this domain. Collaboratively with our partners, the findings from this study will first contribute to understanding how ASWs facilitate exploitation and second how they can become part of the prevention mechanisms and reporters of crimes. METHODS: We present the design of our mixed methods study, underpinned by a peer Action Learning Set (ALS) approach. By working closely with ten survivors of sexual exploitation from 7 countries, the peer group have informed the study through participation in the advisory group, instrument design, implementation, analysis and dissemination. A training and support needs analysis prior to engagement in the research project ascertained what skills people would bring, what they would need for further personal and career development and if there were any additional requirements to enable participation. We provided capacity building through a bespoke training package over the project's lifetime. DISCUSSION: Conducting a peer-researcher ALS project informs the research topic by both empowering survivors of sexual exploitation, whilst engaging with their expertise and lived experience to shape the methods and focus. The summative evaluation of our methods informs wider peer research methodologies, little utilised in the field of MSHT research. Thus, this research produces evidence which acknowledges survivors as experts with value towards social science research.

Social determinants of health and emergency department utilization in Alabama Children's Health Insurance Program.

OBJECTIVES: Injuries are the leading cause of death among children and youth in the United States, representing a major concern to society and to the public and private health plans covering pediatric patients. Data from ALL Kids, Alabama's Children's Health Insurance Program, were used to evaluate the relationship between community-level social determinants of health (SDOH) and pediatric emergency department (ED) use and differences in these associations by age and race. STUDY DESIGN: This was a retrospective, pooled cross-sectional analysis. METHODS: We used ALL Kids data to identify ED visits (injury and all-cause) among children who were enrolled at any time from 2015 to 2017. Exploratory factor analysis was used to categorize SDOH from 18 selected Census tract-level variables. Multilevel Poisson regression models were used to evaluate the effects of community and individual factors and their interactions. RESULTS: Census tract-level SDOH were grouped as low socioeconomic status (SES), urbanicity, and immigrant-density factors. Low SES and urbanicity factors were associated with ED visits (injury and all-cause). The low SES and urbanicity factors also moderated the association between race and ED visits (injury and all-cause). CONCLUSIONS: The environment in which children live influences their ED use; however, the impact varies by age, race, and Census tract factors. Further studies should focus on specific community factors to better understand the relationship among SDOH, individual characteristics, and ED utilization.

Disparities in Telehealth Utilization in a Population of Publicly Insured Children During the COVID-19 Pandemic.

Telehealth became a crucial vehicle for health care delivery in the United States during the COVID-19 pandemic. However, little research exists on inequities in telehealth utilization among the pediatric population. This study examines disparities in telehealth utilization in a population of publicly insured children. This observational, retrospective study used administrative data from Alabama's stand-alone Children's Health Insurance Program, ALL Kids. Rates of any telehealth use for March to December 2020 were examined. In addition-to capture lack of health care utilization-rates of having no medical claims were examined and compared with March to December 2019 and 2018. Multinomial logit models were estimated to investigate how telehealth use and having no medical claims (reference category: having medical claims but no telehealth) were associated with race/ethnicity, rural-urban residence, and family income. Of the 106,478 enrollees over March to December 2020, 13.4% had any telehealth use and 24.7% had no medical claims. The latter was greater than no medical claims in 2019 (19.5%) and 2018 (20.7%). Black and Hispanic children had lower odds of any telehealth use (odds ratio [OR]: 0.81, P < 0.01; OR: 0.68, P < 0.01) and higher odds of no medical claims (OR: 1.11, P < 0.05; OR: 1.73, P < 0.05) than non-Hispanic White children. Rural residents had lower odds of telehealth use than urban residents. Those in the highest family income-based fee group had higher odds of telehealth use than the lowest family income-based fee group. As telehealth will likely continue to play an important role in health care delivery, additional efforts/investments are required to ensure telehealth does not further exacerbate inequities in pediatric health care access.

Characteristics and outcomes associated with two asthma quality of care measures.

OBJECTIVE: We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs). METHODS: Using administrative data from ALL Kids, Alabama's Children's Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean. RESULTS: Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6-20.9) for MMA and 7.3 percentage points (95% CI 2.8-11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3-10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3-26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9-24.2) for non-attainment AMR. CONCLUSIONS: Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.

Harm Reduction and Decriminalization of Sex Work: Introduction to the Special Section.

INTRODUCTION: This special section of Sexuality Research and Social Policy, edited by Belinda Brooks-Gordon, Max Morris and Teela Sanders, has its origins in a colloquium sponsored by the University of Cambridge Socio-Legal Group in 2020. The goal was to promote the exchange of ideas between a variety of disciplinary research fields and applied perspectives on harm reduction and the decriminalization of sex work. The colloquium took place during the emergence of the coronavirus pandemic in February 2020. METHODS: We explore the impact of Covid-19 on understandings of sex work, outline the basic underpinning legal philosophical question, explore the intersectional politics of decriminalization, summarize contemporary international health and human rights campaigns, explore contemporary public opinion trends on the issue, and illustrate the universal principles. Finally, we summarize the special section papers (N=12). RESULTS: The Covid pandemic provided a lens through which to analyse the changes that have occurred in sex work and sex work research in the past decade and it also exacerbated intersecting inequalities, accelerated many social shifts already in motion whilst changing the course of others. In combination the papers in this special issue examine sex work policy and research across 12 countries in four continents to provide and important space for international and cross-cultural comparison. CONCLUSIONS: We present the timely contributions of diverse authors and comment on the significance of their research projects which support a decriminalization policy agenda for the benefit of academics, policymakers and practitioners to improve public health strategies and international responses. POLICY IMPLICATIONS: The research here amplifies the focus on harm reduction and strengthens the case for public policy that decriminalizes commercial sex between consenting adults as the best strategy to reduce harm.

Violent and Nonviolent Crimes Against Sex Workers: The Influence of the Sex Market on Reporting Practices in the United Kingdom.

Previous research has shown that sex workers experience extremely high rates of victimization but are often reluctant to report their experiences to the police. This article explores how the markets in which sex workers operate in the United Kingdom impact upon the violent and nonviolent crimes they report to a national support organization and their willingness to report victimization to the police. We use a secondary quantitative data analysis of 2,056 crime reports submitted to the U.K. National Ugly Mugs (NUM) scheme between 2012 and 2016. The findings indicate that although violence is the most common crime type reported to NUM, sex workers operating in different markets report varying relative proportions of different types of victimization. We also argue that there is some variation in the level of willingness to share reports with the police across the different sex markets, even when the types of crime, presence of violence, and other variables are taken into account. Our finding that street sex workers are most likely to report victimization directly to the police challenges previously held assumptions that criminalization is the key factor preventing sex workers from engaging with the police.

Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya.

This paper uses empirical data collected from 117 female sex workers living in informal settlements in Nairobi and 15 healthcare providers to highlight specific effects of COVID-19 and related restrictions on healthcare access for the sex workers. We highlight the existing gender and health inequalities that have now been reinforced by the initial outbreak of the COVID-19 pandemic. Specifically, we focus on the most concerning healthcare needs for the sex workers including HIV prevention, care and treatment and sexual and reproductive healthcare. Our study findings reveal that the various restrictions imposed by the government to help curb the spread of COVID-19 to a large extent made it difficult for the sex workers to access their healthcare needs. The paper discusses the challenges of healthcare service delivery reflecting on some innovative and pioneering responses from health care providers to address the emergency situation.

Risking safety and rights: online sex work, crimes and 'blended safety repertoires'.

It has been well established that those working in the sex industry are at various risks of violence and crime depending on where they sell sex and the environments in which they work. What sociological research has failed to address is how crime and safety have been affected by the dynamic changing nature of sex work given the dominance of the internet and digital technologies, including the development of new markets such as webcamming. This paper reports the most comprehensive findings on the internet-based sex market in the UK demonstrating types of crimes experienced by internet-based sex workers and the strategies of risk management that sex workers adopt, building on our article in the British Journal of Sociology in 2007. We present the concept of 'blended safety repertoires' to explain how sex workers, particularly independent escorts, are using a range of traditional techniques alongside digitally enabled strategies to keep themselves safe. We contribute a deeper understanding of why sex workers who work indoors rarely report crimes to the police, reflecting the dilemmas experienced. Our findings highlight how legal and policy changes which seek to ban online adult services advertising and sex work related content within online spaces would have direct impact on the safety strategies online sex workers employ and would further undermine their safety. These findings occur in a context where aspects of sex work are quasi-criminalized through the brothel keeping legislation. We conclude that the legal and policy failure to recognize sex work as a form of employment, contributes to the stigmatization of sex work and prevents individuals working together. Current UK policy disallows a framework for employment laws and health and safety standards to regulate sex work, leaving sex workers in the shadow economy, their safety at risk in a quasi-legal system. In light of the strong evidence that the internet makes sex work safer, we argue that decriminalisation as a rights based model of regulation is most appropriate.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies.

BACKGROUND: Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. 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. METHODS AND FINDINGS: We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing. CONCLUSIONS: Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

Devalued, deskilled and diversified: explaining the proliferation of the strip industry in the UK.

This paper looks beyond the debates that focus on the objectification of the female body to examine the question as to why strip clubs have proliferated and found a permanent place in the night-time economy in the UK. Using empirical qualitative and quantitative data from the largest study into the strip industry in the UK to date, we challenge the common assumption that 'demand' is responsible for the rise in erotic dance. Instead, we argue that the proliferation of strip clubs is largely due to the internal economic structures of the industry which have developed partly in response to the financial crisis beginning in 2008. First, we argue that clubs profit from individual dancers through an exploitative system of fees and fines, rendering a strip club business a low cost investment with high returns and little risk to club owners. Second, we note that the last decade has seen diversification of the industry accompanied by deskilling and devaluing of dancing and dancers' labour. Third, we demonstrate that despite the negative effects of these changes on workers, there has been an expansion of the industry as the ability to make profit, even during a financial crisis was ensured through the transferral of risk to workers. Overall, we suggest that far from proliferating as a response to demand, the industry has maintained its market presence due to its ability to establish highly financially exploitation employment relationships with dancers at a time of economic fragility.

Designing out vulnerability, building in respect: violence, safety and sex work policy.

One recent finding about the prostitution market is the differences in the extent and nature of violence experienced between women who work on the street and those who work from indoor sex work venues. This paper brings together extensive qualitative fieldwork from two cities in the UK to unpack the intricacies in relation to violence and safety for indoor workers. Firstly, we document the types of violence women experience in indoor venues noting how the vulnerabilities surrounding work-based hazards are dependent on the environment in which sex is sold. Secondly, we highlight the protection strategies that indoor workers and management develop to maintain safety and order in the establishment. Thirdly, we use these empirical findings to suggest that violence should be a high priority on the policy agenda. Here we contend that the organizational and cultural conditions that seem to offer some protection from violence in indoor settings could be useful for informing the management of street sex work. Finally, drawing on the crime prevention literature, we argue that it is possible to go a considerable way to designing out vulnerability in sex work, but not only through physical and organizational change but building in respect for sex workers rights by developing policies that promote the employment/human rights and citizenship for sex workers. This argument is made in light of the Coordinated Prostitution Strategy.

Female sex workers as health educators with men who buy sex: utilising narratives of rationalisations.

This paper reports on findings from an ethnographic study of female sex workers who work in the indoor sex markets in a British city. An unexpected finding was the collective narratives that sex workers construct to rationalise their involvement in the sex industry. Fifty-five respondents who took part in in-depth interviews maintained that prostitution is a useful occupation and function in society. Narratives included providing emotional support to male clients; a service for men who are socially or physically disabled; preventing men having adulterous affairs; and health education, disease prevention and as therapists for sexual dysfunction. This paper evaluates how the latter narrative of sexual health promotion is an example of how sex workers are ideally placed to work as health educators with men who buy sex. Arguing against gender specific sexual health policies, men who buy sex are described as a 'high risk' group who are also a hidden population. Limitations posed by ideological, ethical and practical concerns relating to the specific conditions of the sex industry suggest that this proposal could be partially successful. In conclusion, I suggest the sexual health of the nation and the place of sex workers in society must be considered with regard to recent policy debates on the management of prostitution and the cultural construction of the sex worker.

A continuum of risk? The management of health, physical and emotional risks by female sex workers.

This paper describes the findings from a 10-month ethnographic study of the female sex industry in a large British city. I argue that sex workers construct a continuum of risk which prioritizes certain types of dangers depending on the perceived consequences and the degree of control individuals consider they have over minimising the likelihood of a risk occurring. Although health-related matters are a real concern to many women, because they generally have comprehensive strategies to manage health risks at work, this risk category is given a low priority compared with other risks. The risk of violence is considered a greater anxiety because of the prevalence of incidents in the sex work community. However, because of comprehensive screening and protection strategies to minimise violence, this type of harm is not given the same level of attention that emotional risks receive. By using a continuum of risk to understand how sex workers perceive occupational hazards in prostitution, further understanding can be gained about the nature of risk in prostitution, sex workers' routines and the organisational features of the sex industry. In addition, the implications for health policy are discussed, suggesting that the emotional consequences of selling sex should be considered as much as the tangible, physical risks of prostitution.