Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies
Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies
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DOI：
10.1371/journal.pmed.1002680
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发表时间：
2018-12-01
期刊：
影响因子：
15.8
通讯作者：
Crago, Anna-Louise
中科院分区：
文献类型：
--
作者：
Platt, Lucy;Grenfell, Pippa;Crago, Anna-Louise
背景性工作者面临着不成比例的暴力、性健康和情绪疾病的风险，这些危害与性工作的刑事化有关。我们综合了性工作法律和治安做法对性工作者的安全、健康和获得服务的影响程度，以及这些影响发生的途径的证据。方法和发现我们搜索了1990年1月1日至2018年5月9日期间的书目数据库，以进行涉及所有性别的性工作者的定性和定量研究，以及与立法、警察和健康相关的术语。我们实施了警察对性工作者或其客户进行合法和非法镇压的类别，包括刑事和行政处罚。我们包括衡量治安与暴力结果、健康和获得服务之间的关联的定量研究，以及探索相关途径的定性研究。我们进行了一项荟萃分析，以估计性/身体暴力、艾滋病毒或性传播感染(STI)以及无安全套性行为的平均影响，与未接触者相比，暴露于压制性警察的个人。定性研究是以迭代、归纳和主题的方式综合的。我们回顾了40篇定量研究和94篇定性研究。对性工作者实施压制性监管与性/身体暴力(优势比[OR]2.99，95%可信区间1.96~4.57)、艾滋病/性传播感染(OR 1.87，95%可信区间1.60~2.19)、无安全套性行为(OR 1.42，95%可信区间1.03~1.94)增加相关。定性综合确定了警察暴力和滥用权力的各种形式，包括任意逮捕、贿赂和敲诈勒索、身体暴力和性暴力、未能提供诉诸司法的机会以及强行进行艾滋病毒检测。它表明，在刑事定罪的背景下，威胁和颁布警察骚扰和逮捕性工作者或其客户的行为，将性工作者赶到与世隔绝的工作地点，扰乱了同伴支持网络和服务渠道，限制了降低风险的机会。它不鼓励性工作者携带避孕套，并加剧了变性人、移民和吸毒性工作者所经历的现有不平等。来自非刑事化环境的证据表明，这些环境中的性工作者与客户有更大的谈判能力，更容易诉诸司法。定量结果受到以下因素的限制：一些结果的荟萃分析的高度异质性，以及对其他结果进行荟萃分析的数据不足，以及不同的样本量和研究质量。很少有研究报告逮捕是否与性工作或其他罪行有关，这限制了我们评估性工作刑事化与与其他惩罚或滥用警察权力相关的结果之间的联系的能力，所有研究都是观察性的，禁止任何因果推断。很少有研究包括跨性别性和顺性男性工作者，除了艾滋病毒/性传播感染检测之外，几乎没有与情绪健康和获得医疗保健相关的证据。结论定性和定量证据一起证明性工作刑事化的广泛危害，包括对性交易和性购买的法律和执法，以及与性工作组织相关的活动。迫切需要改革与性工作有关的法律和体制做法，以减少实现健康的危害和障碍。
BackgroundSex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.Methods and findingsWe searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans-and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.ConclusionsTogether, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.