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Commentary
Widening the harm reduction agenda: From drug use to sex work
Linda Cusick
Institute for Applied Social and Health Research, University of Paisley, The Gardner Building, Paisley PA1 2BE, United Kingdom
Received 27 May 2005; received in revised form 3 November 2005; accepted 6 December 2005
Abstract
Harm reduction emerged in the 1980s as a public health response to HIV and injecting drug use. This paper reviews the literature to structure
the harms associated with sex work and expand the domains of harm reduction. Sex work-related harms are often rooted in debates where
moral arguments and health and criminal justice policies compete for priority. Like drug users, sex workers have a social history in which
they have been stigmatised, criminalised, pathologised, and on occasion, celebrated. Yet, by focusing on drug-related harm specifically, the
harm reduction movement is missing opportunities to better promote health among sex workers. Harms associated with sex work include:
the vulnerabilities that may lead to sex work; harms that are introduced by sex work; and mutually reinforcing harms such as problematic
drug use. These harms are overwhelmingly concentrated in street sex markets and where sex workers pre-existing vulnerabilities can be
most exploited. They include predation and victimisation, violence and child abuse, trafficking and slavery, stigma, sanctions and penalties,
STIs, exposure to mutually reinforcing harms and public nuisance. Existing interventions and policy developments to reduce these harms are
discussed.
2005 Elsevier B.V. All rights reserved.
Keywords: Sex work; Prostitution; Harm reduction; Literature review
Introduction
Applied to drug use, harm reduction principles aim to
reduce individual, community and societal harms including harms to health, social and economic functioning
(Newcombe, 1992). Largely developed to prevent the spread
of HIV and AIDS, harm reduction is contrasted with drug
use prevention and prohibition characterised as the war on
drugs. Riley et al. (1999) describe harm reduction principles as pragmatic, value neutral and focused on prioritising
achievable goals. Lenton and Single (1998) define a harm
reduction policy or programme as one: (1) where the primary goal is the reduction of drug related harm rather than
drug use per se; (2) where abstinence-oriented strategies are
included, strategies are also included to reduce the harm
to those who continue to use drugs; and (3) strategies are
included which aim to demonstrate that, on the balance of
probabilities, it is likely to result in a net reduction in drug
related harm. Harm reduction principles are thus synony
Tel.: +44 141 848 3449; fax: +44 141 849 4264.
E-mail address: linda.cusick@paisley.ac.uk.
0955-3959/$ see front matter 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.drugpo.2005.12.002
and sex workers victimised by predatory pimps, drug dealers, abusers and a host of other players who can profit from
controlling sex workers (Williamson & Cluse-Tolar, 2002).
The experiences and effects of stigma and of physical, sexual and mental abuse are described (Farley, Baral, Kiremire,
& Sezgin, 1998). Opportunities are exposed for the systematic sexual abuse of children through unregulated businesses
and statistics are reported on the prevalence of child prostitution (Munir & Mohd Yasin, 1997; Willis & Levy, 2002).
Trafficking, slavery and debt bondage are linked to health
risk, violence and denial of human rights (Cwikel, Ilan, &
Chudakov, 2003). The risks, incidence and prevalence of
sexually transmitted infection are reported, often alongside
recommendations for sex workers and services to prevent
their transmission (Mayaud & Mabey, 2004; Nagot et al.,
2002). With attention on the potential for sex work to introduce harms to communities, public nuisance is pointed up and
a range of measures suggested to reduce or at least displace
it elsewhere (Benson & Matthews, 1995).
The nature and extent of the harm reported in this literature
varies with the type of sex market studied. Street sex markets
are much more frequently studied and researcher access to
study other types of sex market is often described as problematic (Hart & Whitaker, 1994; Shaver, 2005). When sex
markets are directly compared, the harms introduced by sex
work are overwhelmingly concentrated in street sex markets
and where sex workers pre-existing vulnerabilities can be
most exploited (Church, Henderson, Barnard, & Hart 2001;
Pyett & Warr, 1997).
Benets introduced by sex work
A relatively small literature exists on the potential benefits that sex work may introduce (Chuen-Juei Ho, 2000).
Potentially positive impacts of sex work include positive
body image, job satisfaction, autonomy, control of work
(Manopaiboon et al., 2003; OConnell Davidson, 1998)
and status especially amongst sex workers and the wise
(Goffman, 1963). Positive sexual experience is however,
almost exclusively discussed by sex working authors or with
reference to male sex workers (Minichiello et al., 2001). In
the analysis for this paper, sex work benefits are used as negative cases (Mays & Pope, 2000) to check and improve on
the understanding of associations.
Addiction is frequently associated with sex work and generally discussed in terms of negative consequences for the
sex workers health, safety when working or risk of becoming trapped by the mutually reinforcing aspects of certain
behaviours or substances (Gossop, Powis, Griffiths, & Strang,
1995; Hunter, 2002). Predictably perhaps, drug use is the
principal factor of interest here. There is a huge volume of
literature providing evidence of the extent of overlap between
drug using and sex working populations (Miller & Neaigus,
2002; Morse, Simon, Baus, Balson, & Osofsky, 1992) and the
nature of relationships between various types of sex market
and drug market (Kwiatkowski & Booth, 2000). Other mutually reinforcing behaviours and attitudes include desire for
money to pay for general goods and other lifestyle enhancing
expenses (Hwang & Bedford, 2004). By pointing to commitment and the ongoing nature of lifestyle expenses such
as mortgage repayments and school fees, the literature here
goes further than articles which merely posit desire to escape
poverty as a motivation for sex work. Finally, a small proportion of articles deal with the mutually reinforcing potential of
rewards that are internal to sex work careers. These include
pursuit or enjoyment of sex and the power or status of a
successful sex work career (Weinberg, Shaver, & Williams,
1999).
This commentary provides two lessons for those interested in reducing sex work related harm. First, the literature
on personal and structural factors said to predict, cause or
explain entry to sex work shows that there are many valid
explanations recognising circumstances, motivations and
available options which impact on individuals becoming
sex workers. Second, the literature on the harms said to be
introduced or reinforced by sex work shows that these harms
are not inherent problems of sex work but of vulnerability.
The tasks for harm reductionists in this field may, therefore, be stated as: to reduce existing vulnerability amongst sex
work entrants; and to ensure that sex work does not introduce
further vulnerability.
book on sex work history in the British Library. Organisations differ in their ambitions to abolish/prohibit sex work
with respect to geographic scope (Rouart & Agacinski,
2000; United Nations, 1949) and type of sex work (Holli,
2000; International Programme on the Elimination of Child
Labour, 2002). The success of an abolitionist/prohibitionist
programme might be measured by its impact on the number
of clients, sex workers or sex work premises operating in the
area/sector targeted. Since these impacts are notoriously difficult to demonstrate amongst hidden populations, evidence
often takes the form of case studies in which individuals are
saved from sex work (Yahne, Miller, Irvin-Vitela, & Tonigan,
2002). Meanwhile, the wider literature points to a growth in
the number of sex workers, clients and premises (Raymond,
1998; Weitzer, 2000).
where it has been legalised or licensed (Lewis & MatickaTyndale, 2000; Pyett & Warr, 1997).
One explanation for this relationship is that the illicit
and immoral status of sex work stigmatises and penalises.
Respectable investment and involvement are thereby discouraged and control of sex work left in criminal hands (Brants,
1998). Hence, child abuse, trafficking and slavery are profitable. An extension of this explanation reckons that violence,
stigma and fear of authority are used to manipulate vulnerable
sex workers to further maximise those profits (Kuo, 2002). If
these harms are fostered by the illicit status of sex work, harm
reductionists might tackle that illicit status (Castle, 1995;
Dasgupta, 2002; Gangoli, 1998).
To disentangle sex work from criminal control it will be
necessary to decriminalise sex work and, some also argue,
for sex workers to campaign for their human and employment rights (Kilvington, Day, & Ward, 2001). Decriminalisation and consistent application of legislation as for other
businesses has been demonstrated as effective in reducing
harm in Nevada, USA (Brents & Hausbeck, 2005) and in
The Netherlands (Outshoorn, 2004). In contrast, in Australia
where regulation has been patchy, violence and exploitation
have been concentrated wherever sectors of the sex industry
remain underground and sex workers are criminalised (West,
2000). Meanwhile in France where recent policy has been
influenced by concern about public order, organised gangs
increasingly dominate sex work organisation with subsequent
negative impacts on public health and the living standards of
sex workers (Mathieu, 2004).
To conclude, commercial sex is a suitable area for development of the harm reduction agenda. The current focus on drug
related harm neglects opportunities to reduce these wider
harms.
Acknowledgements
The author is grateful for positive feedback on an oral
presentation of this paper at the sixteenth International Conference on the Reduction of Drug Related Harm, Belfast
2005. Additional thanks are expressed to Prof. Avril Taylor,
Dr Susan Sherman and Dr Marina Barnard for their comments on the drafts of this paper.
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