October 26, 2021
Written by Merrit Stueven, MPP ’22
Edited by Anisha Asundi, WAPPP Research Fellow, and
Moira Notarstefano, WAPPP Communications Manager

Competing strategies to minimize harm and maximize social welfare for sex workers

In her talk for WAPPP’s seminar series on intersectional approaches to gender equity, Professor Manisha Shah discussed her research on the regulation of sex markets. In addition to her own work, Dr. Shah drew on other research to walk the audience through four approaches to regulation: criminalization, decriminalization, the ‘Nordic Model,’ and legalization with regulation.

Dr. Shah grounded her discussion in an overview of sex work, defining it as the “exchange of sexual services for money or goods between two mutually consenting adults” and acknowledged that, while her research focuses on female sex workers and male clients who purchase sexual services, women are not the only suppliers of sex work. The regulation of sex work occurs for various reasons, including a desire to decrease the prevalence of sexually transmitted infections, as well as other potential negative externalities thought to be associated with sex markets such as crime, violence against women, drug use, etc. In addition, regulation is often motivated by a moral opposition to the idea that we can put a price on sex—these policies usually have the underlying goal of ending sex work—a phenomenon that Shah calls “moral repugnance.”

In a market where sex work is criminalized, sex workers—not those buying sexual services—are usually those who bear the consequences. In line with incarceration trends more generally in the US, Black and brown women are disproportionately at risk of being arrested when sex work is criminalized. Similarly, in other countries, women who are most at risk of exploitation are at higher risk when sex work is criminalized. In part, this is because criminalization can drive sex workers underground and into more dangerous working conditions.

Dr. Shah and co-authors Lisa Cameron and Jennifer Seager studied the criminalization of sex work in a natural experiment in East Java, Indonesia. While preparing for another study on sex workers in the region, the mayor of a municipality the researchers were studying shut down the local brothels, effectively criminalizing sex work. Thus, the research team was able to assess the impact of criminalization, using baseline data already collected before criminalization to follow sex workers in this municipality and two other municipalities where sex work was still legal.

After four years, the number of sex workers bounced back to pre-criminalization levels; however, instead of working in safe brothels, sex workers were more likely to be working on the street or in unsafe and unregulated brothels. In addition, sex workers whose work was criminalized had a 27 percentage point, or 58% (from baseline) higher rate of STIs—a result underscored by findings that they were also significantly less likely to use condoms, less likely to get health checks, reported it was more difficult to ask clients to use condoms, and were 50 percentage points less likely to have a condom on them when surveyed. Beyond these direct impacts on health and safe sex practices, Dr. Shah discussed that with criminalization, women’s incomes and happiness decreased while their children saw worse outcomes, including a lower likelihood of going to school and a higher likelihood of working outside the home.

In comparison to these poor outcomes for sex workers and negative externalities for society at large resulting from criminalization, decriminalization is a regulatory strategy that shows promise in improving health outcomes. Decriminalization is the concept of removing criminal penalties for sex work and not enforcing laws that prohibit engagement in the sex market. Dr. Shah and her co-author Scott Cunningham studied the temporary decriminalization of indoor prostitution in Rhode Island, which showed that while the size of the sex market increased after decriminalization, there were significant benefits to the wellbeing of sex workers. For example, after decriminalization, sex workers were 40% less likely to have gonorrhea, a useful proxy for safe sex habits more generally, and rape was 30% lower in the decriminalized Rhode Island than in the control states.

Dr. Shah contrasted these meaningful improvements in the conditions of sex work with the under-studied Nordic Model, also called the ‘end demand’ model. This approach criminalizes the consumption of sexual services, meaning that the clients rather than the sex workers face fines or arrest for engaging in the sex market. This approach has been adopted widely, including in Sweden, Norway, Canada, and France, and is being actively discussed as a regulation model in parts of the US, including New York and California.

Though this model is currently considered best practice in many places, Shah argued that we know little about its impact, and what we do know indicates that sex workers do not benefit from its approach. She cited one study from the UK, which finds that criminalizing the demand for sexual services does not decrease demand, but shifts demand to a riskier group of clients, making sex work more dangerous. A working paper by Riccardo Ciacci corroborates this, showing that in Sweden, as fines for purchasing sex increased, so did the prevalence of rape. Overall, Dr. Shah emphasized that there is not enough research on the end demand model to justify its widespread adoption and, to the contrary, evidence that it may be harmful to sex workers.

Lastly, Dr. Shah discussed legalizing and regulating sex work. Her perspective is that, while this approach can work to improve the health and wellbeing of sex workers, the cost of compliance with regulation is often shouldered by sex workers. Those who cannot afford regular health checks or the costs of being a licensed sex worker, especially sex workers in low-income countries, are more likely to be non-compliant with regulation and resort to sex work in an underground market, again increasing their risk.

Based on the current evidence, decriminalization could be an effective policy to regulate sex markets. Shah recommended further research, including more robust and empirical research on the end demand model. In the conclusion of her talk, Dr. Shah emphasized the agency of sex workers and the importance of centering their needs and their perspectives on the regulation of sex markets as policies are considered and future intersectional research is conducted.