SEX WORKERS AS SAFE SEX ADVOCATES: SEX WORKERS PROTECT BOTH THEMSELVES AND THE WIDER COMMUNITY FROM HIV

Transcription

1 BATES AND BERG SEX WORKERS AS SAFE SEX ADVOCATES AIDS Education and Prevention, 26(3), , The Guilford Press SEX WORKERS AS SAFE SEX ADVOCATES: SEX WORKERS PROTECT BOTH THEMSELVES AND THE WIDER COMMUNITY FROM HIV Julie Bates and Rigmor Berg Since the advent of HIV, significant changes have made the Australian sex industry one of the safest in the world. Creating this safety has been in large part due to the ability of sex workers to act as safe sex advocates through peer-based health promotion; to negotiate with sex business owners; and to inform and participate in the development of government policy. Empowerment of sex workers through legislative reform and government funding of sex worker organizations has been central to the prevention of HV transmission, as has been the development of genuine partnership between sex worker organizations, government departments and those working in public health. The paper describes these responses in some detail and explores some of the current issues facing sex workers in Australia. In Australia today, HIV and other sexually transmissible infection (STI) rates among sex workers are very low, with no recorded cases of transmission from sex worker to client or vice versa and condom use approaching 100% (Donovan et al., 2012). However, when HIV arrived in Australia in the early 1980s, there was potential for the virus to spread rapidly throughout the sex industry and beyond, because condom use was the exception rather than the rule and STI rates among Australian sex workers were comparable to those found in the developing world (Donovan & Harcourt, 1996). It was largely due to the efforts of sex workers themselves that the potential for the rapid spread of HIV throughout the general community was not realized. Their early efforts were supported by health and allied professionals and then by national and state funding for sex worker representative organizations (Donovan & Harcourt, 1996; Mulhall, Hart, & Harcourt, 1995). Collective action was and remains central to this successful response. Australian responses to HIV have generally been pragmatic and bi-partisan, enabling multi-sectoral partnerships involving governments, clinicians, social and Julie Bates was a foundation member of the Australian Prostitutes Collective, served on the Australian National Advisory Committee on AIDS and is now Principal of Urban Realists, providing planning and occupational health and safety advice to the sex industry. Rigmor Berg is Principal of BB Professional Services, providing HIV-related social research, evaluation, and strategic planning consultancy and social impacts expert evidence. Address correspondence to Julie Bates, P.O. Box 559, Darlinghurst, NSW 2010, Australia. julie@ urbanrealists.com.au 191

2 192 SEX WORKERS AS SAFE SEX ADVOCATES epidemiological researchers, and the communities most affected by HIV (gay men, people who inject drugs, and sex workers). Australia had free and confidential sexual health testing and treatment services in place and the adoption of the health promotion approach outlined by the Ottawa Charter (World Health Organization and Welfare Canada, Canadian Public Health, Association, 1986), which recognizes that prevention requires cooperation and empowerment of affected communities, allowed innovative and effective responses to begin early. The Sixth National HIV Strategy (Commonwealth of Australia, 2010) acknowledges that communities affected by HIV are best placed to address HIV risk through funded community organizations that develop and deliver their own styles of health promotion. While HIV prevalence is low in this population, sex workers remain a priority population under the Australian Government HIV/AIDS Strategy (Commonwealth of Australia, 2010) because of the risk of HIV transmission associated with large numbers of sexual partners and the high turnover of sex workers (Donovan et al., 2012). HIV transmission risk is also a function of structural impediments to safe working environments. Although the Australian Government s aim is to ensure that legislation, police practices, and models of regulatory oversight create supportive environments for HIV prevention and health promotion, risk remains where sex workers are isolated from health services and from their peers (Berg, Bates, & Harcourt, 2011; Donovan et al., 2012). Key to ensuring continuing safety in the sex industry is decriminalization of all aspects of adult sex work, with recognition that sex work is legitimate and valued work and that sex workers must be afforded the same human and industrial rights that other workers take for granted. ORIGINS OF THE SEX WORKER RIGHTS MOVEMENT The Sex Worker Rights Movement grew in tandem with the Women s Rights Movement. On June 2, 1975, International Women s Year, several hundred French sex workers took over St. Nizier s Church in Lyon, protesting the social and legal inequities sex workers faced, particularly police harassment and inappropriate responses to crimes committed against them, demanding that sex work be recognized as a job like any other. Strikes and sit-ins in Paris and elsewhere followed (Mathieu, 2001). This date is celebrated globally by sex workers as the beginning of the modern Sex Worker Rights Movement (McNeill, 2012). Similar actions led to the establishment of international networks of support (Kempadoo, 2003). The International Committee for Prostitutes Rights (ICPR) conducted two World Whores Congresses held respectively in Amsterdam in 1985 and Brussels in 1986 and created the World Charter for Prostitutes Rights in 1986 (Pheterson, 1989). This was followed by the global Network of Sex Work Projects (NSWP), 1 which formed in 1991 to promote sex workers health and human rights through member organizations in more than 40 countries. The Asia-Pacific Network of Sex Workers (APNSW) 2 formed in 1994 to facilitate information sharing on tech- 1. See 2. See

3 BATES AND BERG 193 nical and policy issues and advocacy and to build leadership among sex workers regionally. Sex workers from Australia, Thailand, and the USA were involved in high level meetings and consultations with the WHO Global Program on AIDS from the beginning, and strategies and guidelines for the prevention of HIV in sex industries around the world were developed with input from sex workers. PEER-LED SEX WORKER ORGANIZATIONS IN AUSTRALIA Sex worker organizing in Australia began in the late 1970s. Groups such as the Prostitutes Action Group of Victoria, the Australian Prostitutes Collective New South Wales (APCNSW), and the Scarlet Alliance in South Australia, were formed to act as advocates for sex workers on a range of personal, health, industrial and legal concerns (Bates & Sebastian, 1989). From the early 1980s, recognizing the potential of HIV to devastate sex workers lives and livelihoods, these groups formalized their organizations, some with name changes, and new groups emerged in all states and territories. In 1986, the APCNSW became the first group to receive government funding (Donovan & Harcourt, 1996), soon followed by the Prostitutes Collective of Victoria and the Prostitutes Association of South Australia. Funding enabled sex worker groups to elect governing bodies, employ staff, develop programs, and formalize their peer education approaches based on the tradition of experienced sex workers teaching newcomers (Mawulisa, 2002). Because the education programs offered were based on accurate understanding of worker-client and worker-management relationships, were relevant to the lived experiences and concerns of sex workers and were accepted and trusted by sex workers, peer-led programs succeeded in improving working conditions, educating clients, and promoting safe sex practices. These initiatives encouraged sex workers to share skills in the practical application of safe sex principles and built professionalism, pride, and greater assertiveness among sex workers. Sex worker organizations were able to persuade brothel owners that, if they wanted their businesses to survive in the new context of HIV, they must adopt safe sex policies and promote the health of their workers. Furthermore, the setting of boundaries between sex workers and their clients as well as brothel owners resulted, not only in the development of a safe sex culture, but also better attitudes towards sex workers (Mawulisa, 2002). Tracking the new safe sex culture emerging in the sex industry, research conducted by the Sydney Sexual Health Centre found that condom use in Sydney brothels increased from less than 11% of sexual encounters in 1985 to more than 90% in 1989, and the sexual health of sex workers improved commensurately (Donovan & Harcourt, 1996). Health promotion efforts have also focused on migrant sex workers with initiatives such as the multi-cultural peer educator outreach team at Sex Workers Outreach Project NSW and Sydney Sexual Health Centre s community language sex worker clinics. The result was that condom use became the norm in this sector too by the end of the 1990s (Donovan, Harcourt, Egger, & Fairley, 2010; Scarlet Alliance Australian Sex Workers Association and SWOP, 2006). Recent research has shown that condom use in Sydney brothels approaches 100% and that

4 194 SEX WORKERS AS SAFE SEX ADVOCATES the prevalence of four common STIs is now equal to or lower than rates for the general population (Donovan et al., 2012). Today there are funded and unfunded sex worker organizations, groups and projects in all states and territories of Australia. 3 Their common mission is to promote the health, safety, dignity, human rights, and labor rights of sex workers. All actively develop supportive relationships with sex workers and, where appropriate, cooperative relationships with brothel management, health care professionals, and other stakeholders. A combination of health promotion, industrial relations advocacy, support for people affected by anti-trafficking policies, and referral underpin these successful approaches and together they now deliver more than 20,000 occasions of peer support and health promotion service to sex workers each year (Jeffreys, Autonomy, Green, & Vega, 2011). In 1988, the Australian Government funded a consortium of sex worker groups to conduct a national sex worker conference (Sex Industry and the AIDS Debate 88). With a mandate from this conference, the Scarlet Alliance Australian Sex Workers Association was formed in Scarlet Alliance represents sex worker issues at a national level, administers a number of community development and health promotion projects in Australia and the Asia Pacific Region and, in partnership with educational institutions, awards peer educators with a Diploma of Community Education. 4 Their Migration Pilot Project (Scarlet Alliance Australian Sex Workers Association, 2010) provides capacity development and research in relation to the lived experiences of migrant sex workers. LEGISLATIVE REFORMS The UNAIDS Guidance Note on HIV and Sex Work specifies three essential pillars for effective programs: 1: Assure universal access to comprehensive HIV prevention, treatment, care, and support. 2: Build supportive environments, strengthen partnerships, and expand choices. 3: Reduce vulnerability and address structural issues. (The Joint United Nations Programme on HIV/AIDS, 2009, updated 2012, p. 7) Legislative change has been an important aspect of creating supportive environments and addressing structural issues in some parts of Australia. Each state and territory has its own prostitution laws, which currently range from partial decriminalization in New South Wales and the Australian Capital Territory, through licensing with or without registration of sex workers in Victoria, Queensland and the Northern Territory, to prohibition in Western Australia, South Australia, and Tasmania (Harcourt, Egger, & Donovan, 2005). Decriminalization (the removal of most criminal laws pertaining to adult sex work) has emerged as the most successful legislative approach for minimizing harm and improving human rights (Harcourt, Egger, & Donovan, 2005). An extensive study of sex industry outcomes in the capital cities of three different jurisdictions 3. See 4. See

5 BATES AND BERG 195 (NSW with partial decriminalization; Victoria with legalization and licensing and Western Australia with prohibition) found the NSW decriminalization approach to be best practice with regard to public health, human rights, and corruption and crime prevention outcomes (Harcourt, Egger, & Donovan, 2005). Western Australia s prohibition approach had the worst outcomes in terms of access to health services and health promotion programs. The Victorian legalisation with licensing approach was also found to be a threat to public health because it created a twotiered system, in which unlicensed premises and many sex workers, including those working from home or the street and unregistered escort workers, remain criminalized. These criminalized sex workers are much harder for peer educators and sexual health services to reach (Donovan et al., 2012; Harcourt et al., 2010). THE CASE OF NEW SOUTH WALES Because the NSW experience illustrates best practice, it will be described in more detail here. Before 1979, all sex workers in NSW were subject to criminal law and exposed to multiple harms associated with the underground nature of the industry (Harcourt, Egger, & Donovan, 2005). Law reform came in response to government enquiries that revealed a nexus between the sex industry and police corruption (Parliament of New South Wales, 1986; Wood, 1997), as well as concern that HIV would be spread by the sex industry (Donovan & Harcourt, 1996). From 1979, NSW public order laws were reformed: street-based sex work was decriminalized with the repeal of the Summary Offences Act (Parliament of New South Wales, 1986) and the Prostitution Act was amended by the Disorderly Houses Amendment Act 1995, effectively decriminalizing adult sex work (Harcourt, Egger, & Donovan, 2005). The latter legislation made brothels a legal land use to be regulated through environmental planning instruments rather than through the application of criminal law (Harcourt, 1999; Harcourt, Egger, & Donovan, 2005). Decriminalization did not end regulation, however; the sex industry is one of the most highly regulated in NSW (Donovan et al., 2012; Jeffreys et al., 2011). Police responsibilities were replaced by local Council responsibility for development consent and compliance checks, WorkCover NSW responsibility for occupational health and safety and Ministry of Health responsibility for sexual health promotion (Donovan et al., 2012). The reforms allowed sex workers and brothel owners to see themselves as legitimate workers and business people with rights and responsibilities. Most importantly, brothel owners and managers, no longer subject to criminal sanctions, were free to provide condoms and lubricant and to promote safe sex in signage and advertising. The reforms enabled better health service access to sex workers and improved peer education and support opportunities. All of these changes have contributed to improved sexual health outcomes (Donovan et al., 2012), specifically lower STI rates. NSW sex workers not only use condoms, they also avail themselves of voluntary and anonymous testing and treatment as necessary. Mandatory testing in other jurisdictions within Australia has been shown to be counterproductive in terms of sexual health outcomes (Donovan et al., 2012; Jeffreys, Fawkes, & Stardust, 2012), ineffective in reaching the most vulnerable of sex workers (Samaranake et al., 2010), and a waste of public health funds (Wilson et al., 2010). Punishment for transgres-

6 196 SEX WORKERS AS SAFE SEX ADVOCATES sion undermines peer education efforts that depend on access, confidentiality, and trust (Jeffreys, Fawkes, & Stardust, 2012; Matthews, 2008). Decriminalization did not make the sex industry grow or become more obtrusive. Research has shown that the removal of criminal sanctions in NSW did not increase the incidence of commercial sex, nor the proportion of men buying sex services (Donovan et al., 2012) and complaints from neighbors about brothels are rare (Crofts & Prior, 2012; Donovan et al., 2012). Building on this success, in 2012, 50 sex workers, community leaders, human rights activists, advocates, and politicians from Africa, Asia-Pacific, North America, and Europe attended a Sydney symposium organized by the Scarlet Alliance, the Sex Workers Outreach Project of NSW, and the Open Society Foundation to learn about the gains made since decriminalization of the sex industry in NSW and take the best of this model to lobby for decriminalization of sex work in their own countries (Scarlet Alliance Australian Sew Workers Association, 2012). ONGOING CHALLENGES IN NSW While decriminalization has clearly provided the best legal context for good sexual health and human rights outcomes, success in NSW has been limited by poor implementation of the 1995 law reforms (Berg, Bates, & Harcourt, 2011; Donovan et al., 2012; Red & Isbister, 2003). When changed laws brought new responsibilities, it was essential that all stakeholders be given a clear understanding of the rationale underpinning the changes and their own role within the new legal context. To this end, an interdepartmental Brothels Task Force was commissioned in 2000 to monitor the regulation of brothels and assess the success of occupational health and safety programs in NSW. The Task Force found that local Councils needed further support to optimize the potential of the planning system and guidance in the preparation of appropriate planning instruments, development consent conditions, and policies (New South Wales Government, 2001; New South Wales Department of Health and WorkCover, 2001). Best practice guidelines (Sex Services Premises Planning Advisory Panel, 2004) were developed, but were not formally endorsed and implemented. Without the benefit of clear guidelines, there has been great inconsistency in the ways in which local Councils have approached the sex industry, with some readily approving compliant development applications in commercial zones, but others seeking to limit the location of sex industry premises to industrial zones that are deserted at night and therefore unsafe environments for a female workforce and some seeking to prohibit this land use entirely. Because the sex industry continues to exist without development approval when that cannot be obtained, Council refusal to approve compliant applications has created new opportunities for the corruption of public officials, now Council compliance officers rather than police (Donovan et al., 2012). When brothels operate without appropriate development consent, for example as therapeutic or relaxation massage businesses, there is strong disincentive to have safe sex signage or condoms on the premises, because these provide evidence that the premises are actually being used as a brothel (Berg, Bates, & Harcourt, 2011). In these circumstances, sex workers are not supported in insisting on safe sex and

7 BATES AND BERG 197 are less willing or able to access sexual health services or police assistance if they are victims of assault or other crimes. Implementation of the Sex Services Premises Planning Guidelines is essential to ensuring better practice local Council approaches to the regulation of sex industry land use and has been repeatedly recommended (Berg, Bates, & Harcourt, 2011; Donovan et al., 2012). In recent research addressing Eastern Sydney and the Illawarra Region of NSW, Berg, Bates, and Harcourt (2011) reported that some sex workers remain vulnerable due to working in circumstances that are not clearly legal, being isolated from peer support, not identifying as sex workers and/or having some combination of personal issues or disadvantaged minority group membership. Several groups were identified as being more likely to be at risk for HIV and other STIs. The first includes migrant sex workers with poor English language skills and limited sexual health knowledge, who are recently arrived, mainly on visas that allow study with limited hours of work, and who may move frequently from one brothel to another, particularly if they are bonded due to debts incurred in getting to Australia. If they are working in brothels without appropriate development consent and are fearful of Immigration authorities, they may avoid contact with any government services, including sexual health centers. They need to receive information and support in their first language, but may miss visits by the multicultural peer outreach teams, because they are not in any one location for a sufficient length of time. Male sex workers mainly work independently, meeting clients opportunistically or through advertisements on the internet or in gay press. They are less likely to identify as sex workers and less likely to be in touch with other sex workers who could provide peer support and share information. Their main client population (men who have sex with men) has a much higher HIV prevalence than the general population and many favor noncondom HIV risk reduction strategies, such as strategic positioning (avoiding the receptive position), sero-sorting (attempting to avoid partners with different HIV status), or withdrawal before ejaculation, that provide imperfect HIV protection and no protection against some other STIs. Sex workers with complex needs, including people with drug use issues, mental health issues or intellectual disabilities, Aboriginal and transgender people, mainly work from the street, which is only legal if undertaken away from residential areas, schools, hospitals, and churches. This means that they are subject to arrest or police move on orders. This may effectively restrict them to isolated stretches of highway, making them harder for outreach workers to find and leaving them vulnerable to violent or abusive clients. An important initiative in Sydney has been Council approval of safe house brothels that provide short time room rental with security and provision of safe sex supplies for street-based sex workers. HIV-positive sex workers are a small and largely hidden population, a situation entrenched by several instances of heavy handed treatment of identified HIV-positive sex workers. A joint statement by Australian HIV organizations and other public health experts concluded that laws that criminalize HIV-positive people, including sex workers, are inconsistent with current good public health practice and should be repealed (Scarlet Alliance Australian Sex Worker Association, 2008). One HIVpositive sex worker has argued that, if the sex services provided are safe, then HIV status is immaterial and insistence on safe sexual practices is itself a constructive contribution to community education (Berg, Bates, & Harcourt, 2011). Both Mat-

8 198 SEX WORKERS AS SAFE SEX ADVOCATES thews (2008) and Berg, Bates, and Harcourt (2011) have argued that, since some sex workers do continue to work when they have HIV, they should be provided with advice that supports them in doing this safely and policies and procedures should give them no reason to avoid accessing health services. THE STRUGGLE FOR HUMAN RIGHTS, EQUAL STANDING, AND DIGNITY IS NOT OVER Despite decriminalization in NSW, the sex industry in Australia remains highly stigmatized (Donovan et al., 2012), so sex worker organizations continue to lobby for law reform and anti-discrimination protection. While there is clear objective evidence supporting decriminalization and the funding of sex worker rights organizations, a philosophical debate still rages, with potential to reverse the gains described above. In recent decades, the feminist mantle has been claimed by anti-sex work zealots, including Sheila Jeffreys (1997, 2009), Maltzahn (2008) in Australia, and Farley (2007) and Steinem (Kracktivist, 2012) in the U.S., who have conflated sex work with sex trafficking. These abolitionists have promoted the idea that all sex work is intrinsically harmful, exploitative, or coercive and have argued that all sex workers need rescuing and rehabilitation. Coercion and trafficking are serious matters, but this line of argument overestimates the number of people actually affected by sex trafficking (Agustin, 2010; Weitzer, 2012) and fails to recognize that most sex workers are consenting adults who have chosen to do this work (Joint United Nations Programme on HIV/AIDS, 2009), whether as a long-term career or as the best available option to meet their needs for a short period (Berg & Bates, 2008). Migrant sex workers are particularly stigmatized, but research indicates that they often come to Australia because workplaces are safer, free and confidential sexual health services are available, and rates of pay are higher, so they can make a better life for themselves and their families (McMahon, 2006). In their submission to the recent Public Hearing of the Federal Slavery Inquiry, Scarlet Alliance noted the following: In the Australian finalised trafficking cases relating to sex work, all people had consented to sex work and knew they would be a sex worker. Some had sex worked previously. None of the cases involved deception or trickery of the fact the person would be doing sex work therefore in all cases to date the victims were migrant sex workers; migrant sex workers who found themselves in changed or unfair working conditions... (Joint Standing Committee on Foreign Affairs, Defence and Trade, Submission 26, cited in Scarlet Alliance, 2013) There is bitter irony in labeling as feminist any analysis that does not respect the right or ability of adults to make their own choices, but gives support to laws that criminalize the sex industry, despite negative consequences for the health and wellbeing of sex workers. Sex worker organizations and others challenge this rhetoric and punitive legislative approaches, calling for legislation and health programs to be based instead on human rights imperatives and evidence. We turned the tide, along with sex workers around the world, from being seen as vectors of disease to experts with valuable solutions... But now I see that balance slipping back, as some organizations and their leadership attempt to link sex workers to what they want to call sex trafficking. In these campaigns that make no distinction between forced labour or migration and prostitution, they also attack sex workers public health and community organizing projects, like the work done by peer health educators in

9 BATES AND BERG 199 brothels in India, which Gloria Steinem accused of being pimps and traffickers. Why are anti-trafficking advocates disrupting sex workers health projects? (Gira Grant, cited in Ditmore, 2013) The Global Commission on HIV and the Law has also highlighted the harms associated with conflating sex work and sex trafficking and noted that this approach erases the dignity and autonomy of the sex worker in myriad ways. It turns selfdirected actors into victims in need of rescue... (Global Commission on HIV and the Law, 2012, p. 39). This ideological battle matters. Just as legislative reform paved the way to greater safety in the NSW sex industry, there is the potential for legislative change to reintroduce conditions that create risk. Elected officials, whether they are federal or state legislators or local Councillors who make planning decisions, are highly sensitive to public pressure, although this is not always well-informed. Recognizing the problems that arise under prohibition, licensing, and poor regulatory policies, some Australian sex worker groups have chosen to operate without government funding, to ensure that they can engage freely in policy, advocacy, and lobbying work, which some funding bodies currently do not allow. In particular, groups such as VIXEN (Victorian Sex Industry Network), 5 NAUWU (Nothing About Us Without Us) 6 and Touching Base 7 have devoted their efforts to improving the social and cultural position of sex workers and promoting evidence-based best practice, while critiquing poor legislative and regulatory approaches that are discriminatory and inconsistent with sex worker safety and wellbeing. CONCLUSIONS There is much to be proud of in the response of Australian sex workers to the HIV crisis and in the wisdom shown by Australian governments in supporting their efforts. Given an enabling environment, sex workers do provide effective preventive education to their peers and to their clients. The HIV epidemic has also created an opportunity to address some broader issues that affect sex workers lives. Australian research has shown that the decriminalization of adult sex work is the best practical legislative approach to the prevention of HIV and other STIs and also to furthering the human, legal, and industrial rights of sex workers and this is consistent with UN recommendations. Prohibition, legalisation with licensing, and poor regulation in a context of decriminalization can all create harmful consequences for sex workers and for the whole community. It is therefore important that sex worker organizations be allowed to take an advocacy role and contribute to public health policy development and debate on law reform. Attempts to eradicate the sex industry have never succeeded, but the Australian experience has shown that a respectful partnership approach that recognizes the human, legal, and industrial rights of sex workers can make it safe. 5. See 6. See 7. See

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