Elsevier

The Lancet

Volume 366, Issue 9503, 17 December 2005–6 January 2006, Pages 2123-2134
The Lancet

Review
Sex-work harm reduction

https://doi.org/10.1016/S0140-6736(05)67732-XGet rights and content

Summary

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.

Section snippets

Sex-work harms

Differences in social context need to be considered for sex-work harms to be meaningful. In some societies, sex work is legal or decriminalised; sex workers have access to health and social services; and they are not heavily stigmatised or economically destitute.13 Alternatively, sex work could be a survival tactic during severe societal disruption when no services are available and life necessities are scarce.14 Most societies exist between these extremes and sex-work harms thus vary from

Strategies for sex-work harm reduction (table 2)

For centuries, sex workers have faced the harms of sex work. They have developed strategies for understanding their options, modifying their risks, and coping with their situations. Social science publications, especially the autobiographical writings of sex workers, show the logic and power they use in their day-to-day lives.2, 5, 18, 54, 55, 57, 80, 87, 88

Sex workers' coping strategies are based on personal knowledge, tradition and culture, experience, and future plans. Although intended to

Conclusions

The figure shows a conceptual framework for sex-work harm reduction. Poor determinants of health178 are often predisposing factors for individuals entering sex work. Sex workers' personal vulnerability might then act synergistically with a risky environment, exposing them to harms that lead to a reduced quality of life.179 Vulnerability, a risky environment, sex work harms, and diminished quality of life often amplify each other in an ongoing cycle. An objective of harm reduction might be to

Search strategy and selection criteria

For peer-reviewed publications, I searched MEDLINE (from 1966) and EMBASE (from 1980) using the MeSH terms “prostitution” and “risk reduction”. UN, UNAIDS, and WHO publications were searched online with “sex work”, “sex worker”, “sex trade”, “prostitution”, “prostitute”, “survival sex”, “transactional sex”, “harm reduction”, “risk reduction”, “trafficking”, “decriminalization”, and “human rights”. The same terms were used to search psychological, social sciences, and social work

References (179)

  • B Donovan

    Sexually transmissible infections other than HIV

    Lancet

    (2004)
  • Harm reduction approaches to injecting drug use

    (2003)
  • I vanwesenbeeck

    Another decade of social scientific work on sex work: a review of research 1990–2000

    Ann Rev Sex Res

    (2001)
  • ML Rekart

    Sex in the city: sexual behaviour, societal change, and STDs in Saigon

    Sex Transm Infect

    (2002)
  • SO Aral et al.

    The ecology of sex work and drug use in Saratov Oblast, Russia

    Sex Transm Dis

    (2002)
  • N Romero-Daza et al.

    “Nobody gives a damn if I live or die”: violence, drugs and street-level prostitution in inner-city Hartford, Connecticut

    Med Anthropol

    (2003)
  • International Harm Reduction Development programme

  • A Bandes et al.

    Harm reduction and sex work. Harm Reduction Communication

    (2001)
  • Making sex work safe

    (1997)
  • Prostitution de rue: avis

    (2004)
  • Williams C. Reaching women involved in prostitution: a harm reduction strategy of intervention. Durban, South Africa:...
  • LS Stern

    Tricks of the trade

  • Refugees and AIDS. UNAIDS best practice collection

    (1997)
  • Sex work and HIV/AIDS

    (2002)
  • N Persaud et al.

    Sexually transmitted infections, drug use, and risky sex among female sex workers in Guyana

    Sex Transm Infect

    (2000)
  • I Pauw et al.

    “You are just whores—you can't be raped”: barriers to safer sex practices among women street sex workers in Cape Town

    Cult Health Sexuality

    (2003)
  • R de Graaf et al.

    Alcohol and drug use in heterosexual and homosexual prostitution, and its relation to protection behaviour

    AIDS Care

    (1995)
  • DM Patrick et al.

    Incidence of hepatitis C virus infection among injection drug users during an outbreak of HIV infection

    Can Med Assoc J

    (2001)
  • PM Spittal et al.

    Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver

    Can Med Assoc J

    (2002)
  • N El Bassel et al.

    Correlates of partner violence among female street-based sex workers: substance abuse, history of childhood abuse, and HIV risks

    AIDS Patient Care STDS

    (2001)
  • Sex work in Asia

    (2001)
  • E Cohen et al.

    High-risk behaviors for HIV: a comparison between crack-abusing and opioid-abusing African-American women

    J Psychoactive Drugs

    (1994)
  • MH Silbert et al.

    Substance abuse and prostitution

    J Psychoactive Drugs

    (1982)
  • NTT Thuy et al.

    Sexual risk behavior of women in entertainment services

    AIDS Behav

    (2000)
  • KF Trocki et al.

    Alcohol consumption and unsafe sex: a comparison of heterosexuals and homosexual men

    J Acquir Immune Defic Syndr

    (1991)
  • FA Plummer et al.

    The importance of core groups in the epidemiology and control of HIV-1 infection

    AIDS

    (1991)
  • PD Ghys et al.

    Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Cote d'Ivoire, 1991–1998

    AIDS

    (2002)
  • L Morison et al.

    Commercial sex and the spread of HIV in four cities in sub-Saharan Africa

    AIDS

    (2001)
  • M Paris et al.

    Prevalence of gonococcal and chlamydial infections in commercial sex workers in a Peruvian Amazon city

    Sex Transm Dis

    (1999)
  • K Nessa et al.

    Sexually transmitted infections among brothel-based sex workers in Bangladesh: high prevalence of asymptomatic infection

    Sex Transm Dis

    (2005)
  • PJ Feldblum et al.

    Results of a randomized trial of male condom promotion among Madagascar sex workers

    Sex Transm Infect

    (2005)
  • D Kerrigan et al.

    Environmental-structural factors significantly associated with consistent condom use among female sex workers in the Dominican Republic

    AIDS

    (2003)
  • EN Ngugi et al.

    Interventions for commercial sex workers and their clients

  • M Spina et al.

    Human immunodeficiency virus prevalence and condom use among female sex workers in Italy

    Sex Transm Dis

    (1998)
  • SS Liao et al.

    Sex-related health risks and implications for interventions with hospitality girls in Hainan, China

    AIDS Educ Prev

    (2003)
  • KK Holmes

    Human ecology and behavior and sexually transmitted bacterial infections

    Proc Natl Acad Sci USA

    (1994)
  • NS Padian et al.

    Female-to-male transmission of human immunodeficiency virus

    JAMA

    (1991)
  • Cited by (389)

    • Sexual exploitation of trafficked children: Survey evidence from child sex workers in Bangladesh

      2022, Journal of Comparative Economics
      Citation Excerpt :

      This is the first study to analyze the working conditions of trafficked sex workers. Female sex workers earn higher wages than other female workers, but they are exposed to serious harm, such as HIV/AIDs and violence (Arunachalam and Shah 2013; Rekart 2006). Existing studies have shown that the higher wages of female sex workers can be explained as compensation for the loss of future benefits, such as marriage and health.6

    • Human trafficking

      2023, Handbook of Forensic Social Work: Theory, Policy, and Fields of Practice
    View all citing articles on Scopus
    View full text