International Journal of Drug Policy 17 (2006) 3–11


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∗

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mous with the reduction of drug-related harm but it may be possible to apply these principles more widely. As Myers, Aggleton, and Kippax (2004, p. 325) argue, ‘public health seeks critical understanding of issues and promotes the use of community empowerment approaches that are well beyond traditional ones, and harm reduction cannot be constructed in isolation from an understanding of the many social processes that affect health today.’ At present, harm reduction is a feature of sex work interventions mainly where sex workers are a sub-set of problematic drug users (Rogers & Ruefli, 2004). As a result, sex workers who are not problematic drug users are relatively neglected by harm reductionists and the wider problems of sex work fall outside their remits. Those interested in sex work as an area for harm reduction in its own right will nevertheless be able to learn much from existing harm reductionists. Drug users and sex workers after all, share similar social and political histories of being stigmatised, criminalised, pathologised and occasionally celebrated (Sloan & Wahab, 2000). A literature review of sex work harms found three types of association: factors thought to predict, explain or cause sex

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L. Cusick / International Journal of Drug Policy 17 (2006) 3–11

work; harms introduced by sex work; and mutually reinforcing factors. Factors thought to predict, explain or cause sex work In this literature, commercial sex phenomena are described as social problems (Gould, 2001) and in many instances, involvement in sex work is assumed to be a negative experience or an expression of deviance. Background, personal or structural factors are posited to predict, explain or even cause involvement in sex work. This literature tends to be older. In studies of sex work in developed countries, sex work is often depicted as sexual deviance, sexual abuse or the result of ‘a lack’ or ‘failure’ of some kind (Nadon, Koverola, & Schludermann, 1998). Studies of sex work in developing countries draw similar conclusions but also point to explanations for sex work as filial obligation in contexts of cultural acceptance (McCaghy & Hou, 1994). A host of social background and personal factors are associated with entry to sex work and the literature review found no example of a paper that settles on only one explanatory factor. Variously referred to as vulnerabilities, factors, situational and personal variables, characteristics, risks and harms, the list of items thought to lead to sex work includes: pathology, especially mental health (Choicy, 1961); low self-esteem (James & Davis, 1982); childhood neglect or abuse (Dunlap, Golub, & Johnson, 2003; Silbert & Pines, 1981); family (especially maternal) inadequacy (Toby, 1957); moral failing (Denman, 1910) and youth deviance (especially promiscuity in girls) (Davis, 1971; James, 1977). Similarly, a host of structural factors are given to explain sex work and to explain why some individuals become involved in sex work. These include: poverty and a desire to escape it (Muecke, 1992); political instability and war (Richter, 1999); inequality, especially gender inequality (Balos & Fellows, 1999); and lack of education, training or skills for alternative occupations (Rabinovitch & Strega, 2004). Variations on this theme conceive sex work as an outcome of differential association (Sutherland, 1939) and a differential opportunity structure (Cloward & Ohlin, 1960). These sociological theories hold that behaviours and beliefs are learned in specific situations where licit and illicit means to achieving economic success are unevenly distributed. Thus, individuals become sex workers in response to an excess of attitudes favouring sex work which they have learned from others plus relatively good opportunities for doing sex work. Harms introduced by sex work A second type of association indicates harms that are said to be introduced or increased by sex work (Weitzer, 1999). This literature includes articles that may be considered incautious around inferred causality. However, the inferences seem plausible overall. It shows how vulnerability can be exploited

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). Benefits 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; O’Connell 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.

Mutually reinforcing factors This final type of association avoids causal explanations for involvement in sex work but shows connections between sex work and variables that indicate vulnerability (Barnard, 1993). Assumptions about sex workers ‘lacking’ some personal attribute or structural opportunity are less obvious in this literature but ‘spirals of decline’ and the corrosive potential of sex work and its associated variables remain popular themes (Graham & Wish, 1994).

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Addiction is frequently associated with sex work and generally discussed in terms of negative consequences for the sex worker’s 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).

Where do sex work related harms arise? A great variety of types of sex work are revealed in the literature. These are variously distinguished by sex worker demographics, sexual orientation of the client, the physical environment and business operating styles (de Graff, van Zessen, Vanwesenbeeck, Straver, & Visser, 1996; Plumridge, Chetwynd, Reed, & Gifford, 1996). Thus, male/female sex workers, gay/straight clients, indoor/outdoor, and parlour/internet styles emerge as obvious examples of comparative categories. Whether each of these is staffed by a distinct population of sex workers or has a distinct population of clients is not clear (Rissel, Richters, Grulich, de Visser, & Smith, 2003). Nonetheless, sex workers and researchers appear to agree that these categories are meaningful in some way and that they distinguish important features of the various sex markets (Plumridge & Abel, 2001; Rickard & Growney, 2001). Many studies contrast two or more types of sex market. Their overwhelming conclusion is that risk behaviours, harms – and benefits where these are discussed – vary between sex market types (Plumridge & Abel, 2001; Weitzer, 1999). It is clear, therefore, that harms introduced by some kinds of sex work are not introduced to all types of sex work. Violence, for example, is concentrated amongst female sex workers, often soliciting on the streets and providing sex services in isolated and dilapidated environments (Plumridge & Abel, 2001; Surratt, Inciardi, Kurtz, & Kiley, 2004). Similarly, the benefits introduced by some kinds of sex work are not introduced to all types of sex work. The autonomy and control of work-

ing conditions enjoyed by home-based internet-entrepreneurs contrasts sharply with the restrictive rules used to manage some parlour based sex workers (Brewis & Linstead, 2002; Sloan & Wahab, 2000). The greatest concentrations of harms introduced by sex work are described in studies of low status, street based, open sex markets (Miller, 1993; Potterat et al., 2004; Surratt et al., 2004). Characterised by their reputations as ‘problem areas’, these sex markets often co-exist with open drug markets and are not effectively controlled so that violence, child abuse, trafficking and pimping are frequently observed (May, Edmunds, & Hough, 1999). Little is known about the clients using these sex markets although it is thought that more respectable clients are most easily displaced by policing (Cameron, 2004; Hubbard, 1998a; Plumridge et al., 1996). The sex workers operating in these sex markets are almost always described as vulnerable and a host of variables reported which indicate their poor circumstances (Green, Day, & Ward, 2000; Williamson, 2003). Sex workers and clients in these sex markets are the key targets for many services (Jeal & Salisbury, 2004) and are much more heavily policed than other sex markets (Benson & Matthews, 2000). This analysis concludes that sex work conditions are the crucial factor for controlling exposure and vulnerability to the harms that sex work may introduce. This conclusion was examined again using the literature review of ‘benefits introduced by sex work’ as a negative case in analytic induction (Denzin, 1978). Although the literature in this area is much more limited, benefits were linked to conditions in which sex workers had strong control over business arrangements and where they were able to operate without penalties or fear (Plumridge & Abel, 2001; Sanders, 2004). The refined conclusion is, therefore, that the harms and benefits of sex work depend on the conditions in which sex is bought and sold. In summary, this analysis indicates that the ways in which sex work is organised determines whether it introduces harm, increases the vulnerability of sex workers or allows sex workers to benefit from sex work.

The mechanics of deriving harm from sex work A section of the research literature is interested in the actual mechanics or opportunities for harms to be introduced by sex work. With reference to this literature, the question for this paper becomes: what it is about ‘sex work’ that allows these harms to be introduced? From the substantial literature on sexually transmitted infections amongst sex workers we can be confident that these are introduced via the ‘sex’ in sex work. Another substantial literature focuses on drug use or other issues that encourage continuation with sex work: those mutually reinforcing money, status and lifestyle factors. Here, money is the link for reinforcing these harms/benefits. No further harms (or benefits) were identified as arising from the exchange of money and sex. That is, some harms like STIs were introduced by


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sex, other harms like drug dependency were reinforced by availability of money but no additional harms were introduced by the actions of exchanging sex and money. All of the remaining harms identified in the literature as arising from sex work were limited to and dependent on the specific conditions of some sex markets. Each of these is outlined below. Predation and victimisation such as abusive pimping were found in studies of sex markets where sex workers were fearful of authority, isolated and personally vulnerable (Williamson & Cluse-Tolar, 2002). Children, drug users and migrant sex workers who cannot access indoor sex markets, who do not have the resources or confidence to work as entrepreneurs and who do not know enough about their options are the key targets for sex market predators (Nixon, Tutty, Downe, Gorkoff, & Ursel, 2002; Outshoorn, 2001). Paedophiles, pimps, drug dealers and other individuals, often posing as ‘boyfriends’ (Swann, 1999) control and abuse sex workers in sex markets that are not controlled by a gate keeping colleague. By way of contrast, sex markets run from premises controlled by gatekeepers at least comply with enough local legal and social requirements to remain in business: effectively a guarantee of at least some minimum standards (Whittaker & Hart, 1996). Violence and child abuse were found in many sectors of sex work (Raphael & Shapiro, 2004) but the youngest, the most serious assaults and the greatest number of murders were concentrated in sex markets where sex workers worked alone and where they lack status (Pyett & Warr, 1999). Trafficking, slavery and debt bondage were concentrated in large cities and exist in a system suspended between organised crime on the one hand and policing and immigration controls on the other (Chapkis, 2003; Outshoorn, 2001). Fearful of both criminal gangs and authority figures, these sex workers may be controlled, abused and passed around as chattels in a system that prevents them emerging as free citizens. Some trafficked and enslaved sex workers give accounts of being held prisoner while others describe moving around quite freely in their day to day routines but too fearful to attempt escape from the secretive and deprived conditions of their sex markets. Stigma and negative effects on self-esteem or mental health are said to arise from all types of sex work (Chudakov, Ilan, Belmaker, & Cwikel, 2002; Farley, 2003) but the automatic nature of these relationships has been challenged by both academics (Frable, Wortman, & Joseph, 1997; Link & Phelan, 2001) and sex workers who deny their reach (Taylor, 1991). Stigma, reduced self-esteem and negative mental health effects of sex work may, therefore, be introduced by some sex work experiences more readily than others. More research on this topic will be useful but it seems likely that, as with other harms introduced by sex work, these effects are not universal or evenly distributed. State sanctions, penalties and corrupt levies are disproportionately applied to sex workers and their clients in street and other open sex markets (Benson & Matthews, 2000; Fabre, 2001). Otherwise, official police attention is directed

mainly at those who organise and are suspected of making the most substantial profits from indoor sex markets (Mills, 2004; Narboni, 2004). Sex workers who have the assets, knowledge and organisational skills to work collaboratively or independently mainly do so without coming to the attention of the police, services or tax collectors (West, 2000). Viruses do not respect organisational or social distinctions and thus STIs are found amongst sex workers in almost all sex markets (Desai et al., 2003; The Synergy Project, 2002). There are of course some exceptions as some sex markets do not provide physical sexual contact (Exotic Dancer’s Alliance, 2005). Where genital contact is the norm, condoms are widely used and STIs effectively prevented (Kerrigan et al., 2003; Kunawararak et al., 1995). Indeed, in the UK during an epidemic of STIs amongst the general population, their prevalence fell amongst sex workers attending a London clinic (Ward, Day, Green, Cooper, & Weber, 2004). Explaining these findings, Ward et al. (2004) point out that those sex workers who were best able to use condoms in all commercial sex transactions belonged to peer-networks and used their sex work careers strategically. Even here, it appears that opportunities to control the harms that might be introduced by sex work are dependent on the conditions in which sex workers operate (Agha & Nchima, 2004; Pauw & Brener, 2003; Pyett, Haste, & Snow, 1996). The mutually reinforcing harms of sex work and addiction or dependency have been mentioned above. From the high volume of good quality literature on this topic, it is clear that sex workers who appear to be drug users are most often denied work in indoor and co-operative sex work establishments (Plumridge & Abel, 2001). The open, street-based and low status sex markets thus become the only ones accessible to drug using sex workers. These markets are often so strongly entangled with street drug markets that continued and escalating drug use is virtually guaranteed (Inciardi & Surratt, 2001). Exposure to the reinforcing harms of sex work and problematic drug use therefore arise almost exclusively where sex and drug markets share space (May et al., 1999). Public nuisance is introduced by sex markets that are obvious rather than discrete (McKewon, 2003). These are often busy places also populated by the public who are having a night out, sex workers’ clients, drug dealers, drug purchasers and vigilantes with a mission to halt sex markets (Hubbard, 1997, 1998b). Other sex markets may cause public nuisance where they share space with residential or recently gentrified areas, irrespective of whether the sex market or the gentrified property occupiers were the earlier settlers (Kerkin, 2003). Again, the public nuisance harm introduced by sex work is introduced by sex working conditions that are least private, where the most vulnerable sex workers are concentrated and where they can be fully exposed to legal and illegal measures to displace them. In conclusion, the harms that are introduced by sex work depend on sex work taking place in conditions of vulnerability.

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What can be done to reduce sex work related harm? 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. Reducing existing vulnerability amongst sex work entrants Some harm reduction programmes already exist to address the structural factors underlying sex work careers that begin in the context of poor opportunities to pursue alternatives. Education, training and skills programmes are increasingly considered as appropriate interventions (Norton-Hawk, 2001), and are often developed through sex worker initiatives and campaigns (Arnott, 2004). The task of reducing existing vulnerability amongst sex work entrants is nevertheless a daunting one as identified in the literature on those personal, background and structural factors predicting, explaining or causing sex work. Since these factors include personal pathologies, low self-esteem, childhood neglect and abuse, family dysfunction and youth deviance, the harm reductionists who might work in this area will be a much wider group than those whose interests are specifically with sex work. The pre-existing vulnerabilities found amongst sex workers are not unique to this group (Schissel & Fedec, 1999) and neither is it likely that these vulnerabilities first come to light when the vulnerable person becomes a sex worker (Shaw & Butler, 1998; Zigman, 1999). Social, educational and family policies will all have a part to play and there is already a wide literature on best practice for multi-agency working to support vulnerable people (Christian & Gilvarry, 1999; Shaw & Butler, 1998). Similarly, for global problems like poverty, political instability, war and gender inequality, sex work may be an expression of these problems but the solutions do not rest with sex work. Ensure that sex work does not introduce further vulnerability: abolitionist and prohibitionist approaches Some argue that since harms arise from sex work, ideally sex work should be abolished or prohibited using penalties against sex workers, third parties and/or clients to achieve this (Hammer & Maynard, 1987; Jordan, 2002). Such abolitionist and prohibitionist aspirations are mentioned in every

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). Can harm reductionists embrace the abolitionist/prohibitionist ideal? As with abstinence from drug use, there is no reason for harm reductionists to reject the abolitionist/prohibitionist ideal as an end point. However, with reference to drug related harm, Lenton and Single (1998) specifically argue against extending harm reduction definitions to include abstinence or prohibition programmes. They reason that such a definition would be over-inclusive as abstinence programmes cannot reduce harm to current users. Like drug related harms, the harms that are introduced by sex work are currently affecting many vulnerable people and there is a pressing need to reduce them. In a civilised society, responses that might realistically reduce those harms may be valued for their pragmatic and humane qualities. Ensure that sex work does not introduce further vulnerability: challenges for existing harm reduction programmes Sexually transmitted infections, mutually reinforcing aspects of sex work and drug use and public nuisance are all harms which are being tackled by programmes informed by harm reduction principles (Hanslope & Waite, 1994; Smarajit, Basu, Rotherham-Borus, & Newman, 2004). Many of these follow techniques to inform, educate, communicate, reach out and motivate which were developed to reduce drug related harms (WHO, 1995). It is here that those working to apply harm reduction principles to sex work will benefit from the experience of colleagues working to reduce drug related harm (Des Jarlais, 1998; Stimson, 1998). The remaining harms identified in the literature are as follows: predation and victimisation; violence and child abuse; trafficking and slavery; stigma; low self-esteem; mental illness; and the effects of sanctions and penalties. Parallel with the conclusion that these harms arise from the conditions in which sex is bought and sold, they are concentrated where sex work is illicit (Scambler & Scambler, 1995) and have been reduced where it has been decriminalised or in some cases


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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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