A Public Health Approach to Sex Work

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.

Sex workers and sex work in Canada

Canadian researchers and advocates generally understand sex workers to be adults who consensually exchange sexual services for money or goods. Although evidence about the size and demographics of the sex worker population in Canada is limited due to methodological research challenges, it is known that sex workers are persons of diverse racial, cultural and gender identities, ages, sexual orientations, incomes, and education levels. Because of societal conditions sustaining structural disadvantage and limiting economic opportunities, Indigenous, racialized, and immigrant/migrant groups are disproportionately represented among sex workers in Canada (Bungay et al., 2015).

Sex Work Research Methodology
Sex work research involves distinctive methodological challenges stemming from the highly stigmatized and diverse populations involved as well as the risks of criminalization that accompany self-disclosure as a sex worker. High rates of mobility and the relative rarity of physical gathering spaces for sex workers also hamper the recruitment of research subjects (Benoit et al., 2018; Bungay et al., 2015). Challenges also stem from diverging definitions of the category of sex work, often reflecting ideological divisions among researchers as well as heterogeneity among sex workers and the kinds of work they do (Bungay et al., 2015). Because sampling among relatively visible (i.e., street-based) sex workers has dominated the North American sex work research literature base, the realities of male, transgender and off-street sex workers tend to be underrepresented and their perspectives less often recognized in policy and legislative circles (Bungay et al., 2021; Benoit et al., 2022).

Sex work is done in diverse settings, both urban and rural, including outdoor (street-based) locations, indoor locations (commercial venues and worker or client homes) and online (Benoit & Shumka, 2015). Locations and types of sex work tend to correlate with resources and privilege; persons with greater financial, material, and educational resources are more likely to opt for the relative safety and other advantages of online sex work (Machat et al., 2022). While street-level sex work is most visible, researchers believe that the majority of sex work is done in other locations. Some sex workers operate alone part or all of the time, while others routinely work with third-party facilitators such as managers, agency owners, bookers, drivers, website operators, and security personnel.

Indigenous persons are over-represented among sex workers due to past and present-day impacts of racism and colonialism in Canada that sustain structural disadvantage and multiple vulnerabilities. These factors contribute to the relatively higher concentration of Indigenous sex workers within street-level work, with greater risks to their security, health and well-being. The impacts of colonialism are compounded in the context of PCEPA criminalization and associated stigma, leading to more severely negative outcomes for Indigenous sex workers, such as higher rates of HIV, reduced access to health services, greater violence from clients and police, and loss of child custody (Goldenberg et al., 2017a; Crago et al., 2022; Sharma et al., 2021; McBride et al., 2022a).

Indigenous positions on sex work
In 2016, national sex worker advocates called for the perspectives of current Indigenous sex workers to be fully represented in the National Inquiry into Missing and Murdered Indigenous Women and Girls (MMIWG) in order to highlight the ways in which sex work criminalization and over-policing increase vulnerabilities to violence and exploitation (Canadian Alliance for Sex Work Law Reform, 2016). Anti-trafficking views predominated at the 2018 MMIWG Inquiry hearing into human trafficking and sexual violence (Conty, 2019). Although anti-trafficking and anti-sex work perspectives currently prevail among the public positions of many Indigenous communities and organizations, there is increasing openness to sex worker rights approaches among some communities and social service programs in British Columbia, Toronto and Montreal (S. Hunt, personal communication, 10 July 2023).

Migrant sex workers mostly enter Canada legally in search of improved economic opportunities. Contrary to popular impressions that migrants working in ‘massage parlours’ arrive in Canada as victims of sex trafficking, most enter the industry by choice, valuing it as relatively high-paying and flexible, with more stable income, increased autonomy and control, a sense of community, and other social benefits (Malla et al., 2019).

The Canadian legal regime around sex work

Concerns about the impact of Canada’s criminal laws on sex workers’ health, safety and well-being have persisted amid significant changes to these laws over the past decade. In 2013, the Supreme Court of Canada ruled on Canada (Attorney General) v. Bedford, which challenged then-current laws that made it a criminal offense to communicate in public about sex work, to operate or be in a brothel, and to benefit from another person’s earnings through sex work. Invoking section 7 of the Canadian Charter of Rights and Freedoms, the Supreme Court of Canada ruled that those provisions violated sex workers’ right to security by reducing their capacity to work in conditions conducive to their safety.

In 2014, the federal government responded to the Bedford ruling by amending the Criminal Code with the Protection of Communities and Exploited Persons Act (PCEPA). This legislation rests on a view of sex work as inherently exploitative, and aims to eliminate demand for sexual services and protect exploited persons by criminalizing nearly all activities related to the provision and purchase of sex work. Currently criminalized acts include:

• purchasing sexual services, and communicating for the purpose of arranging such purchase;
• communication by sex workers in public areas for the purpose of selling their own sexual services;
• receiving compensation related to someone else’s sale of sexual services;
• facilitating the purchase of someone else’s sexual services; and
• advertising someone else’s sexual services.

Acting on the legislative mandate to review PCEPA, in 2022 the House of Commons Standing Committee on Justice and Human Rights received witness testimony and written briefs. That review produced a report calling on the Government to “recognize that protecting the health and safety of those involved in sex work is made more difficult by the framework set by [PCEPA] and acknowledge that, in fact, the Act causes serious harm to those engaged in sex work by making the work more dangerous” (House of Commons, 2022).

Another major element of the criminal regime around sex work in Canada exists in the Immigration and Refugee Protection Act (IRPR), which prohibits persons who are not citizens or permanent residents from engaging in sex work. If discovered to be doing sex work, migrants who have entered Canada legally are at risk of being deported.

Over the past two decades, the anti-trafficking movement (comprised of groups with a range of ideological positions and interests) has been influential in shaping government policy. This influence is reflected not only in PCEPA, the IRPR, and federal finance-sector regulations (Government of Canada, 2021) but also in program funding distributed to social service providers. As a result, much social sector programming aimed at sex workers currently takes an anti-trafficking approach that requires clients to identify as being exploited and seeking to ‘exit’ from sex work in order to access the services offered.

Impacts of criminalization

One of the most harmful impacts of criminalization is that it pervasively restricts sex workers’ ability to work in conditions that protect their security and health. Both sex workers’ experience and research evidence establish that sex work is not intrinsically dangerous. Multiple research studies have found agreement among sex workers that violence is not inherently part of their occupation, but is exceptional and often stems from a small subset of their clients (Atchison et al., 2015; Bungay et al., 2012; Casey et al., 2017; O’Doherty, 2011). Advertising terms of service and pre-screening clients through communication and contact information decreases the risk of violence for sex workers, as it allows sex workers to avoid intoxicated or aggressive clients and lessens the chances of in-person conflict (McBride et al., 2022b).

Because PCEPA criminalizes the purchase of sex as well as communication for the purchase of sexual services, it severely constrains sex workers’ capacity to communicate with clients and negotiate terms of service (Atchison et al., 2015; McDermid et al., 2022). The inability to screen clients adequately due to fear of police detection more than doubles the likelihood of client violence (Crago et al., 2022). The criminalization of advertising for sexual services further reduces sex workers’ capacity to protect themselves by establishing the terms of sexual services in advance (Bungay & Guta, 2018). Many sex workers use online networks to mitigate the risk of client violence, but the censorship of online content related to sex work has made this more difficult (Bernier et al., 2022). Because client criminalization reduces the pool of clients willing to accept the risk of purchasing sexual services, some sex workers must be less selective in accepting clients, which again increases their risk of experiencing violence (Krüsi et al., 2014). Clients fearing police detection may seek out discreet or isolated meeting locations that leave sex workers even more vulnerable if violence occurs (McDermid et al., 2022). In a legal context in which clients may be more exposed to criminal risk than sex workers, some clients become more aggressive in pursuing their demands, heightening the risk of conflict (McDermid et al., 2022).

As workers who run the risk of experiencing occupational violence, sex workers should, like other workers in Canada, be able to receive police assistance when needed. Under criminalization, however, sex workers are less willing to call police when client violence does occur, or to run the risk of police encounters. Clients know that sex workers’ fear of police may inhibit them from reporting violence; migrant sex workers in particular face increased risks of violence and condom refusal from clients who assume they have less control over terms of service given their migration status, language barriers, and fear of police (Bungay et al., 2012; Goldenberg et al., 2017b; McBride et al., 2020b). A 2022 study across five Canadian cities found that sex workers whose fear of the police would prevent them from calling 911 in an emergency were four times more likely to experience client violence (Crago et al., 2022).

When an interaction with police does occur, it is often unhelpful or harmful to sex workers. This is particularly the case for migrant sex workers in indoor establishments, who face a disproportionate amount of anti-trafficking workplace ‘inspections’ that can result in threats, detainment by law enforcement, and deportation (McBride et al., 2019). The impacts of such inspections on migrant sex workers include significant psychological stress and less access to health services (Ontario HIV Treatment Network, 2012) as well as reluctance to report client violence (McBride et al., 2020a). A study of massage parlour workers in five Canadian cities found that only 5% of workers who contacted the police during a crisis had a positive experience in which police were a source of help (Bungay et al., 2012).

Common experiences of sex workers’ interactions with police include harassment, racism, unwarranted intrusion and ridicule, and sometimes outright physical endangerment. Police violence is experienced more often by Indigenous sex workers, leading to greater endangerment to their health and safety (Argento et al., 2020; McDermid et al., 2022; Crago et al., 2021). In turn, the experience of negative encounters with police is strongly associated with sex workers’ decision to relocate to more isolated locations, which brings higher risk of violence and reduced access to health services; this is particularly true among Indigenous and youth sex workers (Argento et al., 2019a). A 2022 Vancouver-based study found that sex workers who had experienced police harassment faced 1.5 times higher rates of unsuccessful attempts to access substance use treatment, with this correlation holding more strongly for Indigenous sex workers (Goldenberg et al., 2022).

In some contexts criminalization leads to reduced usage of condoms, and thereby to greater risk of sexual infection transmission. As noted above, some clients resist using condoms with migrant sex workers, who they expect to be too afraid to call the police. Furthermore, because police have on occasion used the discovery of condoms carried by an individual or present in indoor premises as evidence that sex work is taking place, some sex workers and establishments do not carry or supply them (Anderson et al., 2016; Collier, 2014).

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.

Addressing intersectionality

Beyond decriminalization, education, and service development, the advancement of health equity requires policy change to transform other societal sectors where stigma and discrimination have the deepest effects on sex workers’ lives. In the words of eminent Canadian researcher Cecilia Benoit, what is problematic in sex work “is largely a problem of social inequality within and across capitalist societies. Unless we address gender inequities alongside economic, race and other injustices, our efforts are impoverished and may even worsen the situation for the diversity of people in sex work” (Benoit, 2021). Taking an intersectional approach to health equity requires addressing colonialism, racism, anti-LGBTQ2S+ discrimination, punitive drug policy, economic precarity, and other forms of structural disadvantage that shape many sex workers’ lives and choices. The path forward for Canada should be modelled on the findings of a 2022 scoping review from Australia:

Existing evidence on sex work under decriminalisation indicates that full sex work decriminalisation is a necessary first step in the effort to improve the health and well-being of diverse sex workers. Crucially, evidence from decriminalised settings highlights that in order to be most effective, legislative change must be accompanied by pursuing social justice and better practice regulatory responses that uphold the intentions of decriminalisation; redistributing resources; addressing structural factors such as unequal access to resources; and tackling intersectional stigma and discrimination. (Macioti et al, 2022).

Sex work research gaps and needs

Reflecting both methodological challenges and the stigmatization of sex workers, the current body of health research on sex workers in Canada is characterized by an imbalanced focus on types of sex work, geographical locations and a narrow focus on negative sexual health outcomes (Bungay et al., 2021). A recent analysis of 64 federal health funding grants for research on sex work between 2003 and 2020 showed a predominance of studies focused on sexual health, with just 3% focused on health services and none focused on clinical research. Most research projects address the behaviours of sex workers, with minimal attention given to structural or social determinants of health outcomes (Benoit et al., 2022).

This narrow research focus constrains the development of evidence-based interventions to improve sex workers’ mental and physical health. Greater research focus on these areas is particularly important given that most sex workers lack access to the occupational health benefits attached to many other jobs, and may be unable to afford health services not covered by public health programs and public insurance (Benoit & Shumka, 2015). Research funding bodies have a responsibility to take note of existing gaps and imbalances in public health research into sex work in Canada and change funding practices in order to establish an evidence-informed research agenda capable of advancing sex workers’ security, health and well-being.

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.

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