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Outreach to sex workers and their clients, not abolitionism, saves lives

I can’t really believe this isn’t so obvious as to go without saying, but yet another peer-reviewed study published in the Lancet this week shows that outreach to sex workers and their clients – including condom distribution, one-on-one safe sex counselling and efforts to reduce stigma – can make a dramatic contribution to HIV prevention. The study was conducted in a number of Indian states over a five-year period.

Sex work in India has a similar status to Ireland: it’s not illegal in and of itself, although many of the surrounding activities (solicitation, brothel-keeping etc) are. A campaign to criminalise clients was opposed by the Ministry of Health and Family Welfare and by the National AIDS Control Organisation, which operates under the Ministry’s aegis, for the precise reason that this would impede the fight against HIV/AIDS. In taking this position, the Indian authorities echo the views of bodies from the World Health Organisation to UNAIDS to the UN Special Rapporteur on the Right to Health, as Stephanie and I noted in this post.

The logic behind this view isn’t difficult. When commercial sex is criminalised – whether for the buyer, seller or both – it hides. The persons involved shy away from social and medical services, due to fear of arrest, of blackmail, of loss of custody of their children, of being treated like deviants. The stigmatisation created by these laws is a powerful force, often overriding even the assurance that sex workers themselves won’t be prosecuted for their activities. This is reflected in a report published earlier this year by the Swedish National Board of Health and Welfare (only in Swedish, unfortunately), which describes on pages 62-63 an interview with a small-town sex worker who admits she does not go for regular HIV testing because of this fear of being identified as a “prostitute” and therefore stigmatised. This can happen even where commercial sex is entirely legal, of course, but there is little dispute among those who work with or study sex workers that the stigma is much greater where it is criminalised.

But that’s not the only problem. Abolitionism is, by its nature, incompatible with harm reduction, and efforts to combat HIV/AIDS often conflict with moral opposition to the behaviours that put people into high-risk categories. This is the case whether we’re talking about sex workers and their clients, injecting drug users or men who have sex with men. But while most western countries, at least, have begun to come to grips with reality in relation to the last two categories, there is still often a stubborn refusal to accept the need to do the same for the first. In Ireland, the main NGO doing outreach to sex workers, Ruhama, offers sex workers cups of tea but not condoms; in Sweden, the Federation for LGBT Rights noted in a report last year (also only in Swedish), on pages 2 and 8, that HIV prevention programmes directed at sex workers and their clients have been blocked because of the state’s zero-tolerance approach to commercial sex. Whatever your personal views of the sex trade, this is fucking crazy.

The evidence that these programmes save lives is so clear that one conclusion is inevitable: to some people, lives are less of a priority than making a “statement” about the morality of the sex trade. They wouldn’t be unique in that view, of course. It’s the same attitude that leads conservative groups to oppose young people having access to condoms, or teenage girls getting the HPV vaccine. But it may go even further than that. Describing the reluctance to adopt measures that could reduce sex workers’ risk of violence, Hilary Kinnell in Violence and Sex Work in Britain theorises at 29-30 that sex work opponents see this violence as a “necessary deterrent”, a warning to people not to enter the sex trade because they might end up dead. If they stop ending up dead, there’s less of a disincentive to doing sex work. And so there’s less of an incentive for sex work opponents to try to prevent sex workers ending up dead.

Some would be outraged by this accusation, but Kinnell didn’t make it up out of nowhere. She cites from a 1977 Observer article in which Polly Toynbee alleges that this was precisely the justification given to her by a Home Office official as to why prostitution should remain “dangerous”. Kinnell writes that “no one would admit that policy is driven by such thinking today” – but this was before Sweden published its 2010 “evaluation” of its sex trade law, which stated that the increased stigma and other negative effects “must be viewed as positive from the perspective that the purpose of the law is indeed to combat prostitution”.  This was before Stockholm Police Superintendent Jonas Trolle told the BBC that “It should be difficult to be a prostitute in our society – so even though we don’t put prostitutes in jail, we make life difficult for them.” These comments don’t state in so many words that they want sex workers to face risks to their health and their lives – but since the increased stigma is itself a risk to their life, as indeed are some of the other ways by which life is “made difficult” for them, that really is what it amounts to.

If abolitionists are genuinely motivated by regard for the well-being of sex workers, they need to explain how this can be reconciled with opposition to programmes that demonstrably improve their health and safety. It’s not enough to simply argue that they are trying to take them out of the high-risk category. People within this category have as much right to health promotion as people in any other. That’s not just my personal view; that’s international law.

And if – like their religious colleagues – they do believe that the threat of serious illness or death is an appropriate tool of social control, then at the very least they should be honest about it and stop dressing up their arguments in the language of concern.

About Wendy Lyon

Fighting a lonely battle for evidence-based policy and the proper use of apostrophes.

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