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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


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
© 2005 Elsevier B.V. All rights reserved.

Keywords: Sex work; Prostitution; Harm reduction; Literature review

Introduction mous with the reduction of drug-related harm but it may be

possible to apply these principles more widely. As Myers,
Applied to drug use, harm reduction principles aim to Aggleton, and Kippax (2004, p. 325) argue, ‘public health
reduce individual, community and societal harms includ- seeks critical understanding of issues and promotes the use
ing harms to health, social and economic functioning of community empowerment approaches that are well beyond
(Newcombe, 1992). Largely developed to prevent the spread traditional ones, and harm reduction cannot be constructed in
of HIV and AIDS, harm reduction is contrasted with drug isolation from an understanding of the many social processes
use prevention and prohibition characterised as the ‘war on that affect health today.’
drugs’. Riley et al. (1999) describe harm reduction princi- At present, harm reduction is a feature of sex work inter-
ples as pragmatic, value neutral and focused on prioritising ventions mainly where sex workers are a sub-set of prob-
achievable goals. Lenton and Single (1998) define a harm lematic drug users (Rogers & Ruefli, 2004). As a result, sex
reduction policy or programme as one: ‘(1) where the pri- workers who are not problematic drug users are relatively
mary goal is the reduction of drug related harm rather than neglected by harm reductionists and the wider problems of
drug use per se; (2) where abstinence-oriented strategies are sex work fall outside their remits. Those interested in sex
included, strategies are also included to reduce the harm work as an area for harm reduction in its own right will
to those who continue to use drugs; and (3) strategies are nevertheless be able to learn much from existing harm reduc-
included which aim to demonstrate that, on the balance of tionists. Drug users and sex workers after all, share similar
probabilities, it is likely to result in a net reduction in drug social and political histories of being stigmatised, crimi-
related harm’. Harm reduction principles are thus synony- nalised, pathologised and occasionally celebrated (Sloan &
Wahab, 2000).
∗ Tel.: +44 141 848 3449; fax: +44 141 849 4264. A literature review of sex work harms found three types of
E-mail address: association: factors thought to predict, explain or cause sex

0955-3959/$ – see front matter © 2005 Elsevier B.V. All rights reserved.
4 L. Cusick / International Journal of Drug Policy 17 (2006) 3–11

work; harms introduced by sex work; and mutually reinforc- and sex workers victimised by predatory pimps, drug deal-
ing factors. ers, 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, sex-
Factors thought to predict, explain or cause sex work
ual and mental abuse are described (Farley, Baral, Kiremire,
& Sezgin, 1998). Opportunities are exposed for the system-
In this literature, commercial sex phenomena are
atic sexual abuse of children through unregulated businesses
described as social problems (Gould, 2001) and in many
and statistics are reported on the prevalence of ‘child prosti-
instances, involvement in sex work is assumed to be a neg-
tution’ (Munir & Mohd Yasin, 1997; Willis & Levy, 2002).
ative experience or an expression of deviance. Background,
Trafficking, slavery and debt bondage are linked to health
personal or structural factors are posited to predict, explain
risk, violence and denial of human rights (Cwikel, Ilan, &
or even cause involvement in sex work. This literature tends
Chudakov, 2003). The risks, incidence and prevalence of
to be older. In studies of sex work in developed countries, sex
sexually transmitted infection are reported, often alongside
work is often depicted as sexual deviance, sexual abuse or the
recommendations for sex workers and services to prevent
result of ‘a lack’ or ‘failure’ of some kind (Nadon, Koverola,
their transmission (Mayaud & Mabey, 2004; Nagot et al.,
& Schludermann, 1998). Studies of sex work in developing
2002). With attention on the potential for sex work to intro-
countries draw similar conclusions but also point to explana-
duce harms to communities, public nuisance is pointed up and
tions for sex work as filial obligation in contexts of cultural
a range of measures suggested to reduce or at least displace
acceptance (McCaghy & Hou, 1994).
it ‘elsewhere’ (Benson & Matthews, 1995).
A host of social background and personal factors are asso-
The nature and extent of the harm reported in this literature
ciated with entry to sex work and the literature review found
varies with the type of sex market studied. Street sex markets
no example of a paper that settles on only one explanatory
are much more frequently studied and researcher access to
factor. Variously referred to as vulnerabilities, factors, situa-
study other types of sex market is often described as prob-
tional and personal variables, characteristics, risks and harms,
lematic (Hart & Whitaker, 1994; Shaver, 2005). When sex
the list of items thought to lead to sex work includes: pathol-
markets are directly compared, the harms introduced by sex
ogy, especially mental health (Choicy, 1961); low self-esteem
work are overwhelmingly concentrated in street sex markets
(James & Davis, 1982); childhood neglect or abuse (Dunlap,
and where sex workers’ pre-existing vulnerabilities can be
Golub, & Johnson, 2003; Silbert & Pines, 1981); family
most exploited (Church, Henderson, Barnard, & Hart 2001;
(especially maternal) inadequacy (Toby, 1957); moral failing
Pyett & Warr, 1997).
(Denman, 1910) and youth deviance (especially promiscuity
in girls) (Davis, 1971; James, 1977).
Benefits introduced by sex work
Similarly, a host of structural factors are given to explain
sex work and to explain why some individuals become
A relatively small literature exists on the potential ben-
involved in sex work. These include: poverty and a desire
efits that sex work may introduce (Chuen-Juei Ho, 2000).
to escape it (Muecke, 1992); political instability and war
Potentially positive impacts of sex work include positive
(Richter, 1999); inequality, especially gender inequality
body image, job satisfaction, autonomy, control of work
(Balos & Fellows, 1999); and lack of education, training
(Manopaiboon et al., 2003; O’Connell Davidson, 1998)
or skills for alternative occupations (Rabinovitch & Strega,
and status especially amongst sex workers and ‘the wise’
2004). Variations on this theme conceive sex work as an
(Goffman, 1963). Positive sexual experience is however,
outcome of differential association (Sutherland, 1939) and a
almost exclusively discussed by sex working authors or with
differential opportunity structure (Cloward & Ohlin, 1960).
reference to male sex workers (Minichiello et al., 2001). In
These sociological theories hold that behaviours and beliefs
the analysis for this paper, sex work benefits are used as ‘neg-
are learned in specific situations where licit and illicit means
ative cases’ (Mays & Pope, 2000) to check and improve on
to achieving economic success are unevenly distributed.
the understanding of associations.
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
Mutually reinforcing factors
doing sex work.
This final type of association avoids causal explanations
Harms introduced by sex work for involvement in sex work but shows connections between
sex work and variables that indicate vulnerability (Barnard,
A second type of association indicates harms that are said 1993). Assumptions about sex workers ‘lacking’ some per-
to be introduced or increased by sex work (Weitzer, 1999). sonal attribute or structural opportunity are less obvious in
This literature includes articles that may be considered incau- this literature but ‘spirals of decline’ and the corrosive poten-
tious around inferred causality. However, the inferences seem tial of sex work and its associated variables remain popular
plausible overall. It shows how vulnerability can be exploited themes (Graham & Wish, 1994).
L. Cusick / International Journal of Drug Policy 17 (2006) 3–11 5

Addiction is frequently associated with sex work and gen- ing conditions enjoyed by home-based internet-entrepreneurs
erally discussed in terms of negative consequences for the contrasts sharply with the restrictive rules used to manage
sex worker’s health, safety when working or risk of becom- some parlour based sex workers (Brewis & Linstead, 2002;
ing trapped by the mutually reinforcing aspects of certain Sloan & Wahab, 2000).
behaviours or substances (Gossop, Powis, Griffiths, & Strang, The greatest concentrations of harms introduced by sex
1995; Hunter, 2002). Predictably perhaps, drug use is the work are described in studies of low status, street based,
principal factor of interest here. There is a huge volume of open sex markets (Miller, 1993; Potterat et al., 2004; Surratt
literature providing evidence of the extent of overlap between et al., 2004). Characterised by their reputations as ‘prob-
drug using and sex working populations (Miller & Neaigus, lem areas’, these sex markets often co-exist with open drug
2002; Morse, Simon, Baus, Balson, & Osofsky, 1992) and the markets and are not effectively controlled so that violence,
nature of relationships between various types of sex market child abuse, trafficking and pimping are frequently observed
and drug market (Kwiatkowski & Booth, 2000). Other mutu- (May, Edmunds, & Hough, 1999). Little is known about
ally reinforcing behaviours and attitudes include desire for the clients using these sex markets although it is thought
money to pay for general goods and other lifestyle enhancing that more respectable clients are most easily displaced by
expenses (Hwang & Bedford, 2004). By pointing to com- policing (Cameron, 2004; Hubbard, 1998a; Plumridge et al.,
mitment and the ongoing nature of lifestyle expenses such 1996). The sex workers operating in these sex markets are
as mortgage repayments and school fees, the literature here almost always described as vulnerable and a host of variables
goes further than articles which merely posit desire to escape reported which indicate their poor circumstances (Green,
poverty as a motivation for sex work. Finally, a small propor- Day, & Ward, 2000; Williamson, 2003). Sex workers and
tion of articles deal with the mutually reinforcing potential of clients in these sex markets are the key targets for many ser-
rewards that are internal to sex work careers. These include vices (Jeal & Salisbury, 2004) and are much more heavily
pursuit or enjoyment of sex and the power or status of a policed than other sex markets (Benson & Matthews, 2000).
successful sex work career (Weinberg, Shaver, & Williams, This analysis concludes that sex work conditions are the cru-
1999). cial factor for controlling exposure and vulnerability to the
harms that sex work may introduce.
This conclusion was examined again using the literature
Where do sex work related harms arise? review of ‘benefits introduced by sex work’ as a negative case
in analytic induction (Denzin, 1978). Although the literature
A great variety of types of sex work are revealed in the in this area is much more limited, benefits were linked to con-
literature. These are variously distinguished by sex worker ditions in which sex workers had strong control over business
demographics, sexual orientation of the client, the physi- arrangements and where they were able to operate without
cal environment and business operating styles (de Graff, van penalties or fear (Plumridge & Abel, 2001; Sanders, 2004).
Zessen, Vanwesenbeeck, Straver, & Visser, 1996; Plumridge, The refined conclusion is, therefore, that the harms and ben-
Chetwynd, Reed, & Gifford, 1996). Thus, male/female efits of sex work depend on the conditions in which sex is
sex workers, gay/straight clients, indoor/outdoor, and par- bought and sold. In summary, this analysis indicates that the
lour/internet styles emerge as obvious examples of com- ways in which sex work is organised determines whether it
parative categories. Whether each of these is staffed by a introduces harm, increases the vulnerability of sex workers
distinct population of sex workers or has a distinct popula- or allows sex workers to benefit from sex work.
tion 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 The mechanics of deriving harm from sex work
way and that they distinguish important features of the various
sex markets (Plumridge & Abel, 2001; Rickard & Growney, A section of the research literature is interested in the
2001). actual mechanics or opportunities for harms to be introduced
Many studies contrast two or more types of sex market. by sex work. With reference to this literature, the question for
Their overwhelming conclusion is that risk behaviours, harms this paper becomes: what it is about ‘sex work’ that allows
– and benefits where these are discussed – vary between sex these harms to be introduced?
market types (Plumridge & Abel, 2001; Weitzer, 1999). It is From the substantial literature on sexually transmitted
clear, therefore, that harms introduced by some kinds of sex infections amongst sex workers we can be confident that these
work are not introduced to all types of sex work. Violence, for are introduced via the ‘sex’ in sex work. Another substantial
example, is concentrated amongst female sex workers, often literature focuses on drug use or other issues that encour-
soliciting on the streets and providing sex services in iso- age continuation with sex work: those mutually reinforcing
lated and dilapidated environments (Plumridge & Abel, 2001; money, status and lifestyle factors. Here, money is the link for
Surratt, Inciardi, Kurtz, & Kiley, 2004). Similarly, the bene- reinforcing these harms/benefits. No further harms (or bene-
fits introduced by some kinds of sex work are not introduced fits) were identified as arising from the exchange of money
to all types of sex work. The autonomy and control of work- and sex. That is, some harms like STIs were introduced by
6 L. Cusick / International Journal of Drug Policy 17 (2006) 3–11

sex, other harms like drug dependency were reinforced by mainly at those who organise and are suspected of making the
availability of money but no additional harms were intro- most substantial profits from indoor sex markets (Mills, 2004;
duced by the actions of exchanging sex and money. All of the Narboni, 2004). Sex workers who have the assets, knowledge
remaining harms identified in the literature as arising from and organisational skills to work collaboratively or indepen-
sex work were limited to and dependent on the specific con- dently mainly do so without coming to the attention of the
ditions of some sex markets. Each of these is outlined below. police, services or tax collectors (West, 2000).
Predation and victimisation such as abusive pimping Viruses do not respect organisational or social distinc-
were found in studies of sex markets where sex workers tions and thus STIs are found amongst sex workers in almost
were fearful of authority, isolated and personally vulnera- all sex markets (Desai et al., 2003; The Synergy Project,
ble (Williamson & Cluse-Tolar, 2002). Children, drug users 2002). There are of course some exceptions as some sex mar-
and migrant sex workers who cannot access indoor sex mar- kets do not provide physical sexual contact (Exotic Dancer’s
kets, who do not have the resources or confidence to work Alliance, 2005). Where genital contact is the norm, condoms
as entrepreneurs and who do not know enough about their are widely used and STIs effectively prevented (Kerrigan
options are the key targets for sex market predators (Nixon, et al., 2003; Kunawararak et al., 1995). Indeed, in the UK
Tutty, Downe, Gorkoff, & Ursel, 2002; Outshoorn, 2001). during an epidemic of STIs amongst the general population,
Paedophiles, pimps, drug dealers and other individuals, often their prevalence fell amongst sex workers attending a London
posing as ‘boyfriends’ (Swann, 1999) control and abuse sex clinic (Ward, Day, Green, Cooper, & Weber, 2004). Explain-
workers in sex markets that are not controlled by a gate ing these findings, Ward et al. (2004) point out that those
keeping colleague. By way of contrast, sex markets run sex workers who were best able to use condoms in all com-
from premises controlled by gatekeepers at least comply mercial sex transactions belonged to peer-networks and used
with enough local legal and social requirements to remain in their sex work careers strategically. Even here, it appears that
business: effectively a guarantee of at least some minimum opportunities to control the harms that might be introduced
standards (Whittaker & Hart, 1996). by sex work are dependent on the conditions in which sex
Violence and child abuse were found in many sectors of workers operate (Agha & Nchima, 2004; Pauw & Brener,
sex work (Raphael & Shapiro, 2004) but the youngest, the 2003; Pyett, Haste, & Snow, 1996).
most serious assaults and the greatest number of murders The mutually reinforcing harms of sex work and addic-
were concentrated in sex markets where sex workers worked tion or dependency have been mentioned above. From the
alone and where they lack status (Pyett & Warr, 1999). high volume of good quality literature on this topic, it is clear
Trafficking, slavery and debt bondage were concentrated that sex workers who appear to be drug users are most often
in large cities and exist in a system suspended between organ- denied work in indoor and co-operative sex work establish-
ised crime on the one hand and policing and immigration ments (Plumridge & Abel, 2001). The open, street-based and
controls on the other (Chapkis, 2003; Outshoorn, 2001). Fear- low status sex markets thus become the only ones acces-
ful of both criminal gangs and authority figures, these sex sible to drug using sex workers. These markets are often
workers may be controlled, abused and passed around as so strongly entangled with street drug markets that contin-
chattels in a system that prevents them emerging as free citi- ued and escalating drug use is virtually guaranteed (Inciardi
zens. Some trafficked and enslaved sex workers give accounts & Surratt, 2001). Exposure to the reinforcing harms of sex
of being held prisoner while others describe moving around work and problematic drug use therefore arise almost exclu-
quite freely in their day to day routines but too fearful to sively where sex and drug markets share space (May et al.,
attempt escape from the secretive and deprived conditions of 1999).
their sex markets. Public nuisance is introduced by sex markets that are obvi-
Stigma and negative effects on self-esteem or mental ous rather than discrete (McKewon, 2003). These are often
health are said to arise from all types of sex work (Chudakov, busy places also populated by the public who are having a
Ilan, Belmaker, & Cwikel, 2002; Farley, 2003) but the auto- night out, sex workers’ clients, drug dealers, drug purchasers
matic nature of these relationships has been challenged by and vigilantes with a mission to halt sex markets (Hubbard,
both academics (Frable, Wortman, & Joseph, 1997; Link & 1997, 1998b). Other sex markets may cause public nuisance
Phelan, 2001) and sex workers who deny their reach (Taylor, where they share space with residential or recently gentrified
1991). Stigma, reduced self-esteem and negative mental areas, irrespective of whether the sex market or the gentrified
health effects of sex work may, therefore, be introduced by property occupiers were the earlier settlers (Kerkin, 2003).
some sex work experiences more readily than others. More Again, the public nuisance harm introduced by sex work is
research on this topic will be useful but it seems likely that, introduced by sex working conditions that are least private,
as with other harms introduced by sex work, these effects are where the most vulnerable sex workers are concentrated and
not universal or evenly distributed. where they can be fully exposed to legal and illegal measures
State sanctions, penalties and corrupt levies are dispro- to displace them.
portionately applied to sex workers and their clients in street In conclusion, the harms that are introduced by sex work
and other open sex markets (Benson & Matthews, 2000; depend on sex work taking place in conditions of vulnerabil-
Fabre, 2001). Otherwise, official police attention is directed ity.
L. Cusick / International Journal of Drug Policy 17 (2006) 3–11 7

What can be done to reduce sex work related harm? book on sex work history in the British Library. Organisa-
tions differ in their ambitions to abolish/prohibit sex work
This commentary provides two lessons for those inter- with respect to geographic scope (Rouart & Agacinski,
ested in reducing sex work related harm. First, the literature 2000; United Nations, 1949) and type of sex work (Holli,
on personal and structural factors said to predict, cause or 2000; International Programme on the Elimination of Child
explain entry to sex work shows that there are many valid Labour, 2002). The success of an abolitionist/prohibitionist
explanations – recognising circumstances, motivations and programme might be measured by its impact on the number
available options – which impact on individuals becoming of clients, sex workers or sex work premises operating in the
sex workers. Second, the literature on the harms said to be area/sector targeted. Since these impacts are notoriously dif-
introduced or reinforced by sex work shows that these harms ficult to demonstrate amongst hidden populations, evidence
are not inherent problems of sex work but of vulnerability. often takes the form of case studies in which individuals ‘are
The tasks for harm reductionists in this field may, there- saved’ from sex work (Yahne, Miller, Irvin-Vitela, & Tonigan,
fore, be stated as: to reduce existing vulnerability amongst sex 2002). Meanwhile, the wider literature points to a growth in
work entrants; and to ensure that sex work does not introduce the number of sex workers, clients and premises (Raymond,
further vulnerability. 1998; Weitzer, 2000).

Reducing existing vulnerability amongst sex work Can harm reductionists embrace the
entrants abolitionist/prohibitionist ideal?

Some harm reduction programmes already exist to address As with abstinence from drug use, there is no reason
the structural factors underlying sex work careers that begin for harm reductionists to reject the abolitionist/prohibitionist
in the context of poor opportunities to pursue alterna- ideal as an end point. However, with reference to drug related
tives. Education, training and skills programmes are increas- harm, Lenton and Single (1998) specifically argue against
ingly considered as appropriate interventions (Norton-Hawk, extending harm reduction definitions to include abstinence or
2001), and are often developed through sex worker initia- prohibition programmes. They reason that such a definition
tives and campaigns (Arnott, 2004). The task of reducing would be over-inclusive as abstinence programmes cannot
existing vulnerability amongst sex work entrants is nev- reduce harm to current users. Like drug related harms, the
ertheless a daunting one as identified in the literature on harms that are introduced by sex work are currently affecting
those personal, background and structural factors predict- many vulnerable people and there is a pressing need to reduce
ing, explaining or causing sex work. Since these factors them. In a civilised society, responses that might realistically
include personal pathologies, low self-esteem, childhood reduce those harms may be valued for their pragmatic and
neglect and abuse, family dysfunction and youth deviance, humane qualities.
the harm reductionists who might work in this area will be
a much wider group than those whose interests are specifi- Ensure that sex work does not introduce further
cally with sex work. The pre-existing vulnerabilities found vulnerability: challenges for existing harm reduction
amongst sex workers are not unique to this group (Schissel programmes
& Fedec, 1999) and neither is it likely that these vulner-
abilities first come to light when the vulnerable person Sexually transmitted infections, mutually reinforcing
becomes a sex worker (Shaw & Butler, 1998; Zigman, 1999). aspects of sex work and drug use and public nuisance are
Social, educational and family policies will all have a part all harms which are being tackled by programmes informed
to play and there is already a wide literature on best prac- by harm reduction principles (Hanslope & Waite, 1994;
tice for multi-agency working to support vulnerable people Smarajit, Basu, Rotherham-Borus, & Newman, 2004). Many
(Christian & Gilvarry, 1999; Shaw & Butler, 1998). Simi- of these follow techniques to inform, educate, communicate,
larly, for global problems like poverty, political instability, reach out and motivate which were developed to reduce drug
war and gender inequality, sex work may be an expression related harms (WHO, 1995). It is here that those working to
of these problems but the solutions do not rest with sex apply harm reduction principles to sex work will benefit from
work. the experience of colleagues working to reduce drug related
harm (Des Jarlais, 1998; Stimson, 1998).
Ensure that sex work does not introduce further The remaining harms identified in the literature are as fol-
vulnerability: abolitionist and prohibitionist approaches lows: predation and victimisation; violence and child abuse;
trafficking and slavery; stigma; low self-esteem; mental ill-
Some argue that since harms arise from sex work, ideally ness; and the effects of sanctions and penalties. Parallel with
sex work should be abolished or prohibited using penalties the conclusion that these harms arise from the conditions in
against sex workers, third parties and/or clients to achieve which sex is bought and sold, they are concentrated where sex
this (Hammer & Maynard, 1987; Jordan, 2002). Such aboli- work is illicit (Scambler & Scambler, 1995) and have been
tionist and prohibitionist aspirations are mentioned in every reduced where it has been decriminalised or in some cases
8 L. Cusick / International Journal of Drug Policy 17 (2006) 3–11

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