A Public Health Perspective on the Relationship between Sex Work and HIV Transmission in Canada

Siobhan Bruce is completing her Masters of Public Health at Queen's University.

The relationship between sex work and human immunodeficiency virus (HIV) has been a longstanding global debate. Global social attitudes vary, with research from some regions indicating that sex work is responsible for high transmission rates while other regions, including Canada, show a very low association.¹ A review of the impact of Canadian sex work legislation, public and self-identified stigma as well as current research evidence paints a more complex and nuanced picture.

Current Sex Work Legislation in Canada
In Canada, sex work is governed under the Protection of Communities and Exploited Persons Act (PCEPA). PCEPA was introduced in 2014 in response to the Bedford v. Canada decision, which determined that previous sex work legislation was unconstitutional and infringed on human rights laws.² Currently the act of selling sex in Canada is legal; however, the necessary actions needed in order to safely facilitate this service are illegal. PCEPA focuses on three separate pillars drawing from the “Nordic model” which aims to ‘end demand’ for sex work. The three pillars include criminalizing public communication of sexual services, criminalizing the purchase of sexual services, and criminalizing third-party involvement in facilitating sex work.^3,4

Stigma
Stigma is extremely prevalent both within and surrounding the sex trade. Sex workers are targets for discrimination and depicted as disrupting families or transmitting sexual diseases4. Public stigma works via discrimination and self-censorship in deterring stigmatized individuals from accessing social services (e.g., healthcare).⁵ Self-stigma is characterized as a process of internalizing negative social perceptions.⁵ Stigma functions to overshadow other facets of an individual’s identity, leaving external status (e.g., occupation) at the forefront of societal perception.⁶ For sex workers, this results in negative stereotypes, discrimination and labels.⁷

Current Evidence
As a consequence of the impacts of stigma, sex workers are often perceived as “vectors of disease”,^8,9 especially HIV. However, this belief is egregiously incorrect and harmful when considered in the Canadian context. The introduction of PCEPA has created precarious working conditions that are closely associated—more so than the practice of sex work per se—with HIV transmission. Sex workers do employ personal health and safety strategies in order to have safe interactions with clients in which HIV transmission is less likely to happen.^9-13 However, the criminalized context of PCEPA presents a range of obstacles to the practice of sex work in conditions under which condom use can reliably happen.^11,14,17

Stigma experienced by sex workers is also associated with reduced access to social services, including healthcare and drug treatment programs.^15,16 Many sex workers are hesitant to disclose their occupation due to fear of judgement by healthcare providers,¹⁵ which can lead to significant reductions in appropriate and timely care. This in turn reduces chances of early detection and exacerbates existing health inequities, promoting the spread of HIV.

Call to Action
Ongoing social perceptions surrounding sex workers and HIV transmission have serious negative implications on their health and wellbeing. The complex political and social environment surrounding sex work requires multidisciplinary policy measure. At the forefront of these must be sex workers’ distinct needs, values and social determinants of health.

Needed policy actions include:

• Full decriminalization to remove the current sex work legislation in Canada, which would ameliorate working conditions and reduce violence.
• Advocacy for the health and occupational rights of sex workers, using research evidence.
• Review and reform of legislation that compounds the effects of sex work stigmatization, particularly in immigration and housing policies.
• Community empowerment to enable sex worker groups to address their priorities.¹⁸

REFERENCES

1. Global Network of Sex Work Projects. Only Rights Can Stop the Wrongs: A Smart Person’s Guide to HIV and Sex Work. Edinburgh, Scotland; n.d. [cited 2023 August 22].
2. Canadian Alliance for Sex Work Law Reform. Canada v. Bedform: The Importance of the SCC Decision. Canada; n.d. [cited 2023 August 22].
3. Canadian Alliance for Sex Work Law Reform. Sex Work and Changes to the Criminal Code After Bill C-36: What Does the Evidence Say? Canada; n.d. [cited 2023 August 22].
4. Canadian Government. Protection of Communities and Exploited Persons Act. Canada; 2014. [cited 2023 August 22].
5. Corrigan P. How stigma interferes with mental health care. American Psychologist. 2004 Oct;59(7):614.
6. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology. 2001 Aug;27(1):363-85.
7. PEERS. Sex work and Stigma. Canada; 2014. [cited 2023 August 22].
8. McBride B, Shannon K, Pearson J, Braschel M, Krüsi A, McDermid J, Goldenberg SM. Association between interrupted access to sex work community services during the COVID-19 pandemic and changes in sex workers’ occupational conditions: findings from a community-based cohort study in Vancouver, Canada. BMJ Open. 2023 Jan 1;13(1):e065956.
9. Benoit C, Shumka L. Sex work in Canada. Understanding Sex Work. 2021 (Updated).
10. McBride B, Shannon K, Murphy A, Wu S, Erickson M, Goldenberg SM, Krüsi A. Harms of third party criminalisation under end-demand legislation: undermining sex workers’ safety and rights. Culture, Health & Sexuality. 2021 Sep 1;23(9):1165-81.
11. Pearson J, Machat S, McDermid J, Goldenberg SM, Krüsi A. An Evaluation of Indoor Sex Workers’ Sexual Health Access in Metro Vancouver: Applying an Occupational Health & Safety Lens in the Context of Criminalization. International Journal of Environmental Research and Public Health. 2023 Jan 19;20(3):1857.
12. McBride B, Shannon K, Pearson J, Krüsi A, Braschel M, Goldenberg SM. Seeing pre-screened, regular clients associated with lower odds of workplace sexual violence and condom refusal amidst sex work criminalization: findings of a community-based cohort of sex workers in Metro Vancouver, Canada (2010-2019). BMC Public Health. 2022 Mar 17;22(1):519.
13. Machat S, Shannon K, Braschel M, Moreheart S, Goldenberg SM. Sex workers’ experiences and occupational conditions post-implementation of end-demand criminalization in Metro Vancouver, Canada. Canadian Journal of Public Health. 2019 Oct;110:575-83.
14. McBride B, Shannon K, Braschel M, Mo M, Goldenberg SM. Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010–2018). Global Public Health. 2021 May 4;16(5):664-78.
15. Ross LE, Sterling A, Dobinson C, Logie CH, D’Souza S. Access to sexual and reproductive health care among young adult sex workers in Toronto, Ontario: A mixed-methods study. CMAJ. 2021;9(2):E482-E490. doi:10.9778/cmajo.20200049
16. Lazarus, L., Deering, K. N., Nabess, R., Gibson, K., Tyndall, M. W., & Shannon, K. (2012). Occupational stigma as a primary barrier to health care for street-based sex workers in Canada. Culture, Health & Sexuality, 14(2), 139-150.
17. Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural and environmental barriers to condom use negotiation with clients among female sex workers: implications for HIV-prevention strategies and policy. American Journal of Public Health. 2009 Apr;99(4):659-65.
18. Shannon K. Lancet Special Issue HIV Sex Work: A community empowerment approach to HIV response among sex workers: effectiveness, challenges and considerations for implementation and scale-up [document on the internet] Canada; n.d. pg. 48.