A Public Health Approach to Sex Work. Canadian position statement

On February 5, 2024, Canadian Public Health Association published official position statement about their view on most effective laws governing sex work. We propose you to read shorter version of this Statement. Full version of this document you could find via this link

The Canadian Public Health Association’s (CPHA) interest in the laws governing sex work began in 1993, in the context of a burgeoning HIV epidemic, when CPHA members debated a resolution calling for “the Government of Canada to rescind legislation that makes solicitation an offense under the criminal code.”

In 2014, CPHA released a position statement that reviewed the available evidence regarding the public health aspects of sex work in Canada and provided recommendations for effective and meaningful public policy on this issue.

Since that time, there have been significant changes in the evidence-based understanding of how conditions in Canadian law, health care and service agencies and other institutions are contributing to inequitable health outcomes for sex workers in Canada. Compared to the overall population, sex workers have greater unmet health needs and greater barriers to accessing the components of health and well-being. Four major factors contribute to this marked health inequity:

• The federal legal regime criminalizing sex work;
• Stigma related to sex work;
• The compounded effects of multiple kinds of structural marginalization; and
• Lack of research knowledge on sex workers’ diverse realities and needs, and effective measures for addressing them.

The purpose of this position statement is to survey current understandings of how these areas of social policy and attitudes contribute to inequitable health outcomes for sex workers in Canada, and to recommend policy measures to address these inequities.

RECOMMENDATIONS

CPHA calls on the federal government to:

• Fully decriminalize sex work by repealing the Protection of Communities and Exploited Persons Act (PCEPA) and removing the Immigration and Refugee Protection Act (IRPR) provision prohibiting migrants in Canada from doing sex work.
• Ensure that sex workers are substantively consulted in the design of laws, policy and programming that bear directly on their health, safety and well-being, with assurance that their identities will be protected during consultation.

CPHA calls on provincial, territorial and regional/local governments to:

• Ensure that health and social service agencies improve the quality of service provided to sex workers by:
  • Training public-facing employees in non-judgemental, trauma- and violence-informed care;
  • Engaging persons with lived experience as sex workers to design and deliver training to eliminate sex work stigma and increase understanding of the diversity of sex workers’ situations and needs; and
  • Implementing operational policies that maintain non-judgemental and culturally-specific services and supports as needed, facilitate access to services, preserve confidentiality of personal information, respect the decision-making agency of clients who do sex work, and recognize that they have physical, emotional, social and psychological health concerns both related and unrelated to their work.
• Fund community sex worker groups to advocate, educate, and deliver programming supportive of sex workers’ security, health and well-being.

CPHA calls on police and law enforcement agencies to adopt training and robust policy measures to eliminate harassment, violence, stigma and discrimination against sex workers by their personnel, and to ensure that police serve appropriately to protect sex workers from violence and coercion.

CPHA calls on professional bodies in health care, mental health, and social service-related fields to require that professional training programs include education about diversity among sex workers, trauma- and violence-sensitive engagement with vulnerable populations, and cultural humility.

CPHA calls on research funding bodies to assess existing gaps and imbalances in research into sex work in Canada, and change funding practices to establish a research agenda that studies the diversity of sex worker populations and health needs, and produces evidence-based policy recommendations and interventions that advance high-quality and accessible health care and social services for sex workers.

A PUBLIC HEALTH APPROACH TO SEX WORK

CPHA’s 2017 working paper Public Health: A conceptual framework states that a public health approach draws on the concept of social justice, understood as “a set of institutions that enable people to lead fulfilling lives and be active contributors to their community”, and grounded in the Canadian Charter of Rights and Freedoms rights to “life, liberty and security of the person”. CPHA’s mission and values includes a particular focus on the health of structurally disadvantaged people and communities, and a commitment “to advocate for the removal of systemic and structural barriers in society to create conditions for equity and ensure that everyone lives with dignity and equal opportunity.”

Such value-based starting points are important to note when health equity for sex workers is at issue. Their work is highly stigmatized in Canadian society, and is opposed by many religious, social and political groups who advocate for policy approaches that are not centred on promoting the security, health and well-being of persons who undertake sex work as an economic activity. Because the lives of this diverse population are shaped by multiple forms of marginalization and vulnerability, a public health approach to sex work must consider these compounding barriers as well.

The promise of decriminalization to advance health equity

A 2018 systematic review and meta-analysis of international research on sex workers’ health outcomes confirmed that the experience of sex workers in Canada under criminalization reflects consistent impacts of criminalization globally: “[E]nacted or feared police enforcement—targeting sex workers, clients, or third parties organising sex work—displaces sex workers into isolated and dangerous work locations and disrupts risk reduction strategies, such as screening and negotiating with clients, carrying condoms, and working with others” (Platt et al., 2018). Global research demonstrates that sex workers experience pervasive harms to their security, health and well-being under criminalization, with subgroups of structurally disadvantaged sex workers who work in riskier conditions experiencing more severe harms.

Because criminalization impedes sex workers’ ability to employ safer-sex strategies including condom use and regular testing for sexually transmitted and blood borne infections (STBBIs), it sustains the conditions under which high rates of STBBI transmission can occur. In 2014, a ground-breaking international study found that a 33‒46% reduction in HIV infections among female sex workers globally could be achieved over the next decade through the decriminalization of sex work (Shannon et al., 2015). For these reasons, both the World Health Organization and UNAIDS have endorsed full decriminalization of sex work as part of measures to end HIV and other STBBIs (World Health Organization, 2022; UNAIDS, n.d.).

The benefits of decriminalization for sex workers’ health and well-being are evident from the decades of evidence available from jurisdictions that have already decriminalized sex work. The most prominent precedent is that of New Zealand, which in 2003 changed its criminal law to provide a legal framework that safeguards the human rights of most sex workers, prevents exploitation, and promotes sex workers’ welfare and occupational health (Van der Meulen, 2011; Lazarus, 2022). The benefits brought about by these reforms are reflected in New Zealand’s ongoing support for sex work decriminalization over the past two decades. Positive outcomes have included better sexual health of sex workers, improved access to health services, and reduced occupational exploitation (Macioti et al., 2022). Decriminalization has increased New Zealand sex workers’ control over labour conditions, increased condom use, and decreased STBBI prevalence (Canadian Alliance for Sex Work Law Reform, 2017). The exception to these outcomes, however, is the population of migrant sex workers in New Zealand, whose work remains criminalized and who continue to suffer negative health outcomes.

Full decriminalization of sex work means removing criminal prohibitions for all sex workers, including migrants. The two jurisdictions worldwide that have fully decriminalized sex work without restrictions on location or against migrants holding work visas are the Northern Territory of Australia (in 2019) and Belgium (in 2022); research evidence on the health impacts of these changes is not yet available (Macioti et al., 2023).

In order for sex workers’ occupational health and safety to be protected following decriminalization, a whole-of-government approach to develop regulation for the sex industry will be needed. Measures to prevent and remedy labour exploitation, as well as other health and safety measures, must be designed in consultation with sex workers in order to ensure that anti-exploitation policies do not constrain their ability to work and live with access to the same services and supports as other Canadians.

Impacts of sex work stigma

Because the causes of health inequities among sex workers in Canada go beyond the legal regime governing sex work, additional policy measures are needed to remove barriers sex workers face in accessing the conditions supporting health and well-being. A major source of these barriers is sex work stigma, which influences policing as well as health and social service provision.

Stigma surrounding sex work reflects cross-cultural legacies that viewed persons who sell sexual services as morally and socially inferior, as embodiments of societal deficiencies, and as vectors of STBBIs. Impacts of this stigma profoundly shape sex workers’ lives, including their self-perception and mental well-being; their ability to gain emotional and social support from family, friends and community; and their treatment by police, and health and social service providers (Benoit et al., 2018). These impacts may be compounded by the impacts of intersecting stigma affecting sex workers who belong to other structurally disadvantaged groups (e.g., immigrant or migrant, Asian, Indigenous, and LGBTQ+ sex workers) (Sou et al., 2017; Socías et al., 2016; Lyons et al., 2019).

Pervasive stigma (compounded by ignorance about sex work and the diverse realities of sex workers) restricts sex workers’ access to appropriate health care in multiple ways. It leads care providers to have unfounded judgements and assumptions about their sex worker clients’ working practices and lives, and to treat them in disrespectful, paternalistic ways. In the sphere of mental health care, stigma can lead providers to see sex work as the entirety of a client’s identity, preventing understanding of more complex factors underlying the client’s mental health (Bungay & Casey, 2019). Ignorance of or indifference to the harms produced by stigmatization and criminalization result in health providers failing to meet sex worker clients’ need for their personal information to be kept highly confidential or anonymized.

Stigma also leads health care providers and health systems to adopt an overly narrow focus on STBBIs. This occurs notwithstanding the reality that they are not intrinsically correlated with sex work, that most sex workers are experts in safer sex practices, and that many are regularly tested for STBBIs. Higher than average rates of STBBIs among sex workers in Canada correlate with belonging to other structurally disadvantaged and stigmatized population groups, including people who use injection drugs (Ontario HIV Treatment Network, 2012; Argento et al., 2019a; Rusakova et al., 2015; Shannon et al., 2007), Indigenous sex workers (Argento et al., 2019a), migrant sex workers (McBride et al., 2022a; McBride et al., 2020b), and male sex workers (Baral et al., 2015). Effective sexual health services for these populations requires specifically designed programming and skilled caregivers who understand the complex contexts and needs of these groups.

The over-preoccupation by health care systems and providers on sex workers’ sexual health means that physical and mental health needs may go unaddressed and unmet (Bungay & Casey, 2019). Health system assumptions pertaining to street involvement, substance use, poverty, and agency are significant in shaping sex workers’ access to health care (Bungay, 2013). Documented experiences include:

• providers who assume that sex worker patients lack control or self-discipline, leading the provider to choose a treatment for the patient with minimal consultation;
• an overemphasis on substance use, even with patients who do not use drugs;
• refusal to provide appointments for treatment, based on the assumption that sex workers are substance users and incapable of keeping a scheduled appointment; and
• refusal to provide treatment due to assumptions of drug-seeking behaviour (Shannon et al., 2007).

All of these effects of stigma can lead workers to avoid disclosing their occupation in contexts when disclosure is salient for quality care, and in some cases to avoid encounters with health providers for both routine and urgent care (Lazarus et al., 2012; Ross et al., 2021). These circumstances exacerbate existing health issues for many sex workers, and delay detection of newly emerging issues. Ultimately, the effects of stigma contribute to the outcome that sex workers are significantly less likely than other Canadians to report good or excellent health (Benoit et al., 2016).

Sex workers report mental and emotional health as the most difficult aspects of their health to sustain, experiencing higher than average levels of depression, anxiety and post-traumatic stress disorder (Benoit & Shumka, 2015; Benoit et al., 2022), with those who are marginalized on multiple fronts facing higher levels of mental health challenges (Harris et al., 2023; Argento et al., 2019b; Lyons et al., 2019; Sou et al., 2017). Work-related stress among sex workers in Canada is significantly associated with older age and Indigeneity, as well as the poor working conditions and unhealthy coping behaviours associated with criminalization (Sou et al., 2018; Duff et al., 2017).

Health systems and providers can respond effectively to these specialized health needs only if they are aware of the diversity of sex work and sex workers, and trained in non-stigmatizing and culturally sensitive care. Involving sex worker organizations in the development and delivery of education for health care providers, and in the design and delivery of health care programming for their peers, is essential to producing effective results (Bungay & Casey, 2019). Research in the mostly decriminalized jurisdictions of New Zealand and New South Wales in Australia has shown positive results from peer-based health promotion programs that employ staff who are culturally and linguistically diverse, with connections to transgender, migrant, and Indigenous communities (Macioti et al., 2022).

Given how often sex workers experience harassment and disrespectful treatment by police forces in Canada, anti-stigma education about sex work is also needed as part of police training in working with structurally disadvantaged populations.

CONCLUSION

In order for Canada to live up to its commitment in the Canadian Charter of Rights and Freedoms to guarantee everyone in this country the rights to “life, liberty and security of the person”, institutions and individuals must re-examine longstanding and highly harmful attitudes towards sex work. As a first step, the Protection of Communities and Exploited Persons Act (PCEPA) should be repealed. Legislative solutions, however, are only the first step. The systemic stigmatization of sex work and sex workers must be eliminated through enhanced education and training for health and social service providers as well as law enforcement agents in every jurisdiction. Sex workers should be at the centre of planning programs and services that support their health and well-being, and research funding bodies should redress gaps and imbalances in sex work research.

Canadian Public Health Association’s (CPHA)