Illustration by Lydia Fu

Stigma Puts Sex Workers at Higher Risk of HIV

Diana Tourjée

Diana Tourjée

Sex workers and other marginalized demographics have always bore the brunt of cultural stigma around HIV. More than thirty years after the onset of the AIDS epidemic, the disease persists, with real people paying the price.

Illustration by Lydia Fu

Like any other industry, sex work comes with its own job-related risks. The possibility of acquiring an STI, like HIV, is a concern, as are threats to physical and mental health; however, unlike other professions where risk is curbed through standard health and safety regulations, society has made sex work unnecessarily dangerous. Stigmatization—which ranges from the public perception of sex workers as morally corrupt and socially unproductive, to laws that criminalize their profession—is central to that. While stigma itself can easily marginalize and alienate a demographic, a series of intersecting stereotypes and inequities coalesce for sex workers

Earlier this year, sex worker and advocate Grace Bellavue died by suicide; before her passing, she had been a fierce advocate for decriminalization. The note she left on her Facebook page before taking her own life account spoke to the harrowing, horrifying reality she endured as a sex worker: "It isn't the industry per say, it's just accumulated PTSD and constantly guarding your back or screening... I've had guns put to my head, yelled at too many people, removed people from clubhouses, been approached by lawyers from all sides of the fence, approached to run parlours [sic], watched a lot of people slip and fall in a bath with the their throat slit," she wrote.

Many argue this kind of violence and risk is amplified because of the criminalization of sex work, not the other way around. In the wake of Bellavue's passing, sex workers have called for mental health services that are customized for their needs. Could the violence that traumatized Bellavue been stopped if her profession were not illegal in her state?

Karma, a sex-positive feminist, says she entered the sex industry after becoming fascinated by Bellavue's work and other high profile sex workers in college. "I read their blogs, looked into various brothels and escort agencies around Sydney," she told Broadly in an email. "I considered stripping (too uncoordinated), sugaring (too much effort), [and] being an independent escort (steep learning curve)." She eventually decided to on a fancy brothel in Sydney called Stilleto because, as she noted, "Time Out magazine described it as the 'Taj Mahal' of Sydney brothels." Karma was given an interview and was so eager to begin that she jumped straight on a bus from her school's school library to the brothel. That was two and a half years ago. She's been a sex worker ever since.

For many sex workers, the stigma of the sex industry prevents them from accessing adequate health care.

"Stigma against sex workers is a huge negative influence on mental health," Karma said. She has an excellent vantage point. Unlike Bellavue, she lives in a state where prostitution is decriminalized. Because she works in a legal brothel, Karma says she's in in a fairly safe environment—but she understands the risks of the trade very well. "The fact that it is legal and legitimate creates less room for intolerance," she said. She thinks she deals with less judgment from others, including friends and acquaintances, because her work has not been made criminal. That's a big deal because social rejection plays a significant role in marginalization, which isolates people from the resources meant to protect them. For many sex workers, the stigma of the sex industry prevents them from accessing adequate health care—which puts them at increased risk of contracting HIV/AIDS.

It's been more than three decades and the epidemic of HIV/AIDS is far from over. The UNAIDS 2015 fact sheet states that 36.9 million people were living with HIV at the end of last year, and that 25.3 million have died from AIDS related complications since the year 2000. Less than half of those living with the disease are currently accessing antiretroviral medication. But new infections have dropped 35 percent in the last fifteen years, giving hope to leaders in the fight to end AIDS.

HIV/AIDS is not just an illness. The epidemic initially took hold within gay male subcultures in the 1980s; because American society was intensely homophobic at that time, the cultural perception of HIV/AIDS fused with existing prejudices. American citizens were dying by the thousands before anything was done to understand or end the public health crisis. Because AIDS impacted a marginal, stigmatized group, it was allowed to persist—the disease was killing mostly gay men in metropolitan tenderloins, and it was known as the "gay cancer." Despite the passage of time, and educational, advocacy work that has striven to correct inaccurate stereotypes about HIV/AIDS, stigma persists worldwide: Even today, more than thirty years later, HIV diagnoses are burdened with undue stigma. And, for populations that are already marginalized, like sex workers, the stigma of HIV/AIDS is particularly dangerous because it magnifies otherwise manageable risk.

It isn't possible to end HIV until stigma and its reflection in biased laws and policies are eliminated.

Catherine Hanssens is the founder of The Center for HIV Law and Policy (CHLP). Her organization works for the rights of people affected by HIV. Hanssens told Broadly, "It isn't possible to make a full life possible for people living with HIV, let alone end HIV, until stigma and its reflection in biased laws and policies are eliminated." Since CHLP formed, the organization has focused on "the conditions and discrimination imposed on young people in detention and foster care facilities, and the horrific injustice and pubic health inconsistency of HIV criminal laws," Hanssens said. "If anything, we have increased our focus on the intersection of HIV, the criminal justice system, and the social/political capital of affected populations. That is where the rubber hits the road, in my opinion."

The organization is working against the systems that stigmatize HIV. Those prejudices and biases are widespread, neither singular nor simple. CHLP Co-Director Allison Nichol explained, "There are many stigmas in play related to the spread of the [HIV] virus. Stigma attached to homelessness, poverty, unemployment, overuse of drugs and alcohol, disabilities including mental illness, GLBTI status, and sex work, among others, all can play a role."

Lack of research is part of the problem. Broadly contacted the Center for Disease Control (CDC) seeking comment about the prevalence of HIV/AIDS in the sex worker community. Brian Katzowitz from CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention responded stating that, "Unfortunately, we have virtually no data on prevalence of HIV among [the sex worker] population so there's not a lot of insight we can provide."

"HIV/AIDS is still stigmatized," Karma said. Sexual health is a primary concern for many sex workers, but that's not always enough to stay protected, she noted, arguing that the only true solution is to eradicate all laws that criminalize the profession and institute protective policies and practices to empower and benefit sex workers health, success, and well-being.

Sex workers are a key population for HIV transmission risk. Stigma, marginalization, and risk exist wherever punitive laws against sex work are in place.

Pepi Rodriguez, the coordinator of CHLP's program to provide youth in state custody to comprehensive, LGBTQI-inclusive, sexual health care and education, agrees: Without legislative support, self-advocacy and best safety practices will always fall short, he told Broadly. "Despite being more knowledgeable, generally, than the general population about sexual health and risk reduction strategies, sex workers are a key population for HIV transmission risk," he said. "Stigma, marginalization, and risk exist wherever punitive laws against sex work are in place: 116 countries, as of 2012." Rodriguez noted that, in countries that have decriminalized sex work, the profession is burdened only by standard occupational health and safety regulations. "These countries have higher rates of condom use, and sex workers are able to organize community-based health practices that demonstrably improve health and reduce HIV risk."

In August of this year, the global human rights organization Amnesty International (AI) called for the universal decriminalization of consensual sex work. AI Secretary General Salil Shetty said, "Sex workers are one of the most marginalized groups in the world who, in most instances, face constant risk of discrimination, violence and abuse." This incited global discourse on the decriminalization of sex work.

As Karma sees it, Sydney and Melbourne are inspiring models for other regions because they have progressive prostitution laws. "There are still people who don't 'get' it," she wrote, "but the fact that it is legal and legitimate creates less room for intolerance. Decriminalization is a huge step in reducing the stigma of sex work, or any other victim-less 'crimes' such as drug use."

According to Karma, in Australia, rates of HIV infection are lower in female sex workers compared to the general population and this is "due to decriminalization, education, access to health services and diligence in using condoms and practicing safer sex—our bodies are our business so it is in our best interest to protect it." (She's citing data put out by AIDS 2014, the 20th annual AIDS conference in Melbourne, Australia.)

As many as a quarter of street-based sex workers report feeling pressured to have sex with a client without using a condom.

According to a study released by UK medical journal The Lancet in 2014, in areas where sex work is recognized as a legitimate profession, the likelihood of acquiring HIV is reduced by 32 percent. Criminalization raises HIV risk in sex work populations in part by discouraging as much as one third of sex workers from carrying protection: In some regions, condoms constitute evidence of illegal sex work.

The risks facing sex workers vary drastically from region to region, as well as between the different forms of sex work that people engage in. While Karma works in a legal brothel, many sex workers in the world do not have that choice. "Only about 20 percent of sex workers in the United States are street-based," Rodriguez said. "Most sex workers see clients in massage parlors, brothels, shared housing, or hotel rooms, often connecting and arranging meetings with clients online." Rodriguez explained that people who practice sex work on the street are subject to a higher incidence of violence both from their clientele and abusive law enforcement. "Further, risk reduction strategies, such as screening clients during price and condom use negotiations, are jeopardized, since fear of law enforcement crackdowns compel sex workers to move quickly and cut these negotiations short. This diminishes sex workers' ability to screen out clients with whom they may not feel safe."

If a client does become violent, street-based sex workers don't have the protection that others might. Rodriguez says that these risks "may be fueled by clients' knowledge that sex workers often have no legal recourse." And this doesn't just put sex workers at a risk of physical violence. As Rodriguez noted, "As many as a quarter of street-based sex workers report feeling pressured to have sex with a client without using a condom. This is exacerbated in jurisdictions with 'condoms as evidence' policies and practices." Judging by the statements of CHLP, and Karma's experience, systems of law are not serving sex workers. Their lives are put at risk because they are criminalized and stigmatized, pushed far from the resources the rest of society relies upon.

There are many well-known and documented factors that coalesce causing HIV/AIDS to persist. These factors we as a society created.

"I've only walked out on a couple of bookings," Karma said. "One, because the client repeatedly tried to kiss me on the mouth despite not paying the additional fee. Another because he was just really rude and disrespectful. I realize I'm very lucky to have not had to deal with a forceful client, because many other girls have had bad experiences with this. I have never felt in danger at work. The establishment offers security. There are cameras everywhere but inside the rooms, a security guard on duty and an intercom in every room. I've have not contracted an STI since I started working in this industry."

Mayo Schreiber is an expert in criminal law and the Deputy Director of CHLP. According to him, "there are many well-known and documented factors that coalesce causing HIV/AIDS to persist." They're not outside of us, or somehow foreign to the way we live. "These factors we as a society created and sanctify," Shreiber said. "They are the result of national and local political decisions for which we are responsible: HIV criminal laws that stigmatize and harshly punish people who take the responsibility to get tested or sex workers who carry condoms, a lack of syringe exchange programs, a lack of sexual health programs or condoms in prisons and jails, the failure to provide affordable health insurance and housing for all our citizens, the failure to provide comprehensive sexual health literacy programs (particularly for young people), parental refusal to accept adolescents' sexual orientation or gender identity that force them onto the streets, etc.

"These factors have the greatest impact on those in our nation with the least amount of political and economic capital—the young, the impoverished, people of color, men who have sex with men, transgender people, persons who overuse drugs, sex workers, prisoners. It is primarily they who bear the brunt of the political decisions allowing HIV/AIDS to exist. But it is everyone in this country that pays the price."