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Criminalisation of clients : reproducing vulnerabilities for violence and poor health among street-based… Krüsi, Andrea; Pacey, Katrina E.; Bird, Lorna; Chettiar, Jill; Allan, Sarah; Bennett, Darcie; Montaner, Julio; Kerr, Thomas; Shannon, Kate Jun 2, 2014

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Criminalisation of clients: reproducingvulnerabilities for violence and poorhealth among street-based sex workersin Canada—a qualitative studyA Krüsi,1 K Pacey,2 L Bird,3 C Taylor,1 J Chettiar,1,3 S Allan,1 D Bennett,2J S Montaner,1,4 T Kerr,4,5 K Shannon1,4To cite: Krüsi A, Pacey K,Bird L, et al. Criminalisationof clients: reproducingvulnerabilities for violenceand poor health amongstreet-based sex workers inCanada—a qualitative study.BMJ Open 2014;4:e005191.doi:10.1136/bmjopen-2014-005191▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2014-005191).Received 5 March 2014Revised 4 May 2014Accepted 21 May 2014For numbered affiliations seeend of article.Correspondence toDr K Shannon;gshi@cfenet.ubc.caABSTRACTObjectives: To explore how criminalisation andpolicing of sex buyers (clients) rather than sex workersshapes sex workers’ working conditions and sexualtransactions including risk of violence and HIV/sexuallytransmitted infections (STIs).Design: Qualitative and ethnographic studytriangulated with sex work-related violence prevalencedata and publicly available police statistics.Setting: Vancouver, Canada, provides a uniqueopportunity to evaluate the impact of policies thatcriminalise clients as the local police departmentadopted a sex work enforcement policy in January2013 that prioritises sex workers’ safety over arrest,while continuing to target clients.Participants: 26 cisgender and 5 transgender womenwho were street-based sex workers (n=31) participatedin semistructured interviews about their workingconditions. All had exchanged sex for money in theprevious 30 days in Vancouver.Outcome measures: Thematic analysis of interviewtranscripts and ethnographic field notes focused onhow police enforcement of clients shaped sex workers’working conditions and sexual transactions, includingrisk of violence and HIV/STIs, over an 11-month periodpostpolicy implementation ( January–November 2013).Results: Sex workers’ narratives and ethnographicobservations indicated that while police sustained ahigh level of visibility, they eased charging or arrestingsex workers and showed increased concern for theirsafety. However, participants’ accounts and policestatistics indicated continued police enforcement ofclients. This profoundly impacted the safety strategiessex workers employed. Sex workers continued tomistrust police, had to rush screening clients and weredisplaced to outlying areas with increased risks ofviolence, including being forced to engage inunprotected sex.Conclusions: These findings suggest thatcriminalisation and policing strategies that target clientsreproduce the harms created by the criminalisation ofsex work, in particular, vulnerability to violence and HIV/STIs. The current findings support decriminalisation ofsex work to ensure work conditions that support thehealth and safety of sex workers in Canada and globally.INTRODUCTIONHarassing the clients is exactly the same asharassing the women. You harass the clientsand you are in exactly the same spot youwere before. I’m staying on the streets. I’min jeopardy of getting raped, hurt.––Jasmine, cisgender woman sex workerThere is now a well-established body of epi-demiological and social science research glo-bally pointing to the negative impact oflegislation and policies that criminalise sexwork on violence and other health risksincluding HIV/sexually transmitted infection(STI) among sex workers.1–7 The criminalisa-tion of some or all aspects of prostitutionremains the dominant legal approach glo-bally,1 4 despite growing empirical evidenceand clear international guidelines by theStrengths and limitations of this study▪ This is the first empirical study of how criminal-isation and policing of sex buyers shapes sexworkers’ risks for violence and poor health,outside of a small body of research inScandinavia.▪ This study draws on data of the lived experiencesof sex workers from 31 qualitative interviews tri-angulated with ethnographic observations, sexwork-related violence prevalence data and pub-licly available police statistics.▪ The data represented in this study reflect theexperiences of primarily street-based sexworkers, disproportionately impacted by policingand thus, may not be representative of othersegments of the sex industry.▪ This study is a qualitative evaluation post-implementation of a new enforcement policytargeting sex buyers rather than sex workers,and as such, likely underestimates the full impactof any legislative change to criminalise thepurchasing of sex.Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191 1Open Access ResearchWHO, UNAIDS, UNDP and UNFPA calling for fulldecriminalisation of sex work as necessary to promotingthe health and human rights of sex workers (see onlinesupplementary materials for a summary of legal andregulatory responses to sex work).Enforcement-based approaches and policing withincriminalised frameworks have consistently been linked toelevated risks for violence, and reduced ability to negoti-ate safer sex transactions, including prevention of HIVand other STIs.1–3 6 8 Previous research indicates that incriminalised settings, policing strategies can range fromsurveillance and crackdowns to arrests or threats of arrest,intimidation by police, and police violence can be fre-quent and can go largely unreported.2 9–12 These risksare amplified for the most marginalised and visible sexworkers, those living in poverty and working on thestreet.10 13 14 In an effort to avoid police, sex workersoften move to outlying secluded areas to meet andservice clients where there are few to no protections fromviolence and abuse, and reduced ability to refuseunwanted clients or services, including client demandsfor sex without a condom.9 10 15–17 Criminalisation andpolicing force sex workers to rush or forgo screening pro-spective clients or negotiating the terms of sexual transac-tions before entering a vehicle, placing sex workers atincreased risk of physical violence, rape and HIV/STIs.9 18 19 Criminalisation of sex work also impedesaccess to safer indoor work environments, particularly forthose most socially and economically marginalised.Previous research undertaken in Canada and internation-ally has indicated that indoor sex work environments withstructural supports, including supportive managementpolicies, security measures and access to HIV/STIs pre-vention resources, increase sex workers’ control oversexual transactions with clients, including protectionsfrom violence, abuse and HIV/STIs, and promote sexworkers’ ability to access police protections in cases ofviolence.17 20 21The criminalisation of sex work has also been foundto prevent sex workers from reporting violent perpetra-tors and seeking legal recourse after physical or sexualassault.9 22 There is also growing evidence that legisla-tion criminalising sex work constitutes a significantbarrier to accessing healthcare services, includingprimary care, HIV treatment and prevention and sexualhealth services.16 23 24 Additionally, stigma and discrim-ination against sex workers are significantly amplified insettings where sex work is criminalised, and furtherreduce sex workers’ ability to access police protectionsor health and social support services.23 25Demand criminalisationOver the past decade, there has been increased interestby a number of higher income countries to attempt toeradicate prostitution through ‘demand criminalisation’,which criminalises the purchase, but not the selling, ofsexual services. Sweden, Norway, Iceland and mostrecently France opted for ‘demand criminalisation’,despite the lack of evidence supporting this legal frame-work. Similarly, the European Union has also recentlyvoted in favour of implementing this approach.26‘Demand criminalisation’ was first implemented inSweden in 1999. The primary objective of the law is toeradicate prostitution by eliminating demand. However,evidence from Sweden indicates that the law has beenunsuccessful in meeting this objective.27 Instead, anumber of unintended consequences have beenreported—namely, that it drives sex workers and clientsunderground to more clandestine locales, and is diffi-cult to enforce due to the unwillingness of sex workersto testify against their clients.28 29The Canadian contextCanada is at a critical time in the evolution of its legalresponse to sex work. In December 2013, Canada’shighest court, the Supreme Court of Canada, unani-mously struck down Canada’s core prostitution laws,deeming them unconstitutional for violating sexworkers’ constitutional rights, including the ability toprotect themselves from violence, abuse and HIV/STIs.30 The three laws struck down included prohibi-tions on communicating in public for the purpose ofprostitution (sex workers or clients), operating a bawdyhouse and living off the avails of prostitution. Similar tothe UK and other commonwealth countries, theCanadian Criminal Code has never criminalised thebuying or selling of sex per se, however the laws prohibitvirtually every other aspect of sex work, making it effect-ively impossible to engage in sex work legally. The hyp-ocrisy of the criminalised prostitution laws and theunintended harms on sex workers’ safety, health andhuman rights were a critical reason for the decision ofSupreme Court of Canada.30 The Court suspended thedecision for 1 year to provide the Canadian governmenttime to respond by either removing the struck down lawsfrom the Criminal Code (and thus decriminalising sexwork), or by bringing the laws governing prostitution inline with the decision. Following the decision, theCanadian government has moved quickly towards callingfor criminalising the purchase of sex,31 despite a lack ofevidence that this change would address the harms asso-ciated with criminalised and quasi-criminalisedapproaches of regulating prostitution.New sex work enforcement policy in Vancouver, CanadaVancouver, Canada, provides a unique opportunity toevaluate the potential impact of laws and policies thatcriminalise sex buyers (clients). In January 2013, theVancouver Police Department (VPD) officially adoptednew sex work enforcement guidelines that shifted thefocus in policing sex work away from arresting or press-ing charges against sex workers. These sex work enforce-ment guidelines emerged after two decades oftremendous violence and murder of street-based sexworkers and strong pressure from sex work and othercommunity organisations, legal experts and academic2 Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191Open Accessresearchers calling for reforms to local policing practicesto better protect, rather than increase harm, isolationand risk of violence to sex workers.32 The sex workpolicing guidelines set out a strategy to ‘open communi-cation’ with sex workers and prevent violence against sexworkers through prioritising their safety over enforce-ment measures such as arrest.33 However, the policingguidelines did not address changes in enforcement ofclients. In fact, on their website the VPD confirms thatthey continue to “target both pimps and customers, inlocations where the impact of the sex trade has becomeunacceptable.”34 The result is that as of January 2013,Vancouver has been a de facto ‘demand criminalisation’environment.Therefore, the objectives of this study are to evaluatehow a new local enforcement strategy that targets clients,but not sex workers, shapes sex workers’ interactions withpolice and negotiation of their working conditions andsexual transactions with clients, with a particular focus onprotections from violence and HIV/STIs.METHODSThis study is situated within a larger National Institutes ofHealth (NIH)-funded longitudinal qualitative and ethno-graphic research project investigating the structural andphysical, social and policy features of work environmentsshaping sex workers’ sexual health, violence and access tocare in Vancouver, Canada. The research builds on long-standing partnerships and a community advisory boardwith sex worker, community, policy and health stake-holders since 2004, and runs alongside a sister projectknown as AESHA (An Evaluation of Sex Workers’ HealthAccess). The AESHA cohort is a community-based longi-tudinal study of over 800 sex workers with biannualfollow-up, focused on evaluating the physical, social andpolicy environments shaping sexual health, violence, HIVvulnerability and access to care among sex workers.35 Theresearch and outreach team include experiential andnon-experiential staff.This study draws on ethnographic fieldwork of street-based sex work scenes and qualitative semistructuredinterviews with street-involved sex workers about theirworking conditions, interactions with police and negotia-tions of health and safety with clients in the city ofVancouver, Canada, over 11 months ( January–November2013), following the implementation of the new sexwork enforcement guidelines by the VPD in January2013. Qualitative and ethnographic data were triangu-lated with sex work-related violence prevalence datafrom the AESHA cohort prepolicy and postpolicy imple-mentation and publicly available police statistics thatreport on prostitution-related criminal code offences inthe city of Vancouver.36The lead author (AK) and coauthor ( JC) conductedmore than 40 h of ethnographic observation withinknown street-based sex work strolls in the city ofVancouver to assess level of police presence; shifts inworking areas and police, sex worker and client interac-tions. All ethnographic observations were conductedwithin the context of regular weekly AESHA outreachshifts, which included provision of harm reduction sup-plies, food and referrals to social and health supports.Observation sessions lasted 3–5 h and took place duringpeak hours of sex work activity between 22:00 and 3:00.AK and JC recorded brief fieldnotes in a research logduring the observation sessions and elaborated on themafter each observation outing.Interview participants were recruited through purpos-ive sampling from the longitudinal cohort (AESHA),and aimed to reflect variation in demographics (eg, age,ethnicity and gender) and work environments (eg, geo-graphic neighbourhoods, variation in street and off-street solicitation and transaction spaces). Eligibilitycriteria for the in-depth interviews included: (1) currentsex work defined as exchanged sex for money in thepast 30 days in the city of Vancouver; (2) identifying ascisgender or transgender woman and (3) aged 18 yearsor older. While the larger qualitative and ethnographicresearch and AESHA projects focus on a diversity ofstreet and off-street (eg, indoor and online) sex workenvironments, this specific study aimed to examine theexperiences of street-involved sex workers (ie, those soli-citing and/or servicing on the street) given substantialdata that criminalisation and enforcement dispropor-tionately target this segment of the sex industry.10 13 14 Itshould be noted that even within this context, manystreet-involved sex workers worked in street and off-streetvenues, including online and indoor informal andformal venues (see results).The 31 semistructured interviews were conducted bytwo experienced qualitative interviewers (CT and AK)and facilitated by an interview guide encouraging broaddiscussions of working conditions, police presence andinteractions and negotiation of health and safety intransactions with clients, post-VPD policy implementa-tion ( January 2013). The interview guide was developedbased on existing knowledge of the research team andin collaboration with our sex worker, community andpolicy partners. We conducted all interviews at one ofthe two field offices in the city of Vancouver. Interviewslasted between 45 and 90 min, were audiorecorded,transcribed verbatim and checked for accuracy. All parti-cipants provided informed consent and were remuner-ated with a $C30 honorarium for their time, expertiseand travel.Interview transcripts and ethnographic data were ana-lysed using thematic analyses to examine sex workers’interactions with police and negotiation of their workingconditions and sexual transactions with clients, includingprotections from violence, abuse and HIV/STIs, postpo-licy implementation. All textual data were analysed usingan inductive and iterative process facilitated by the quali-tative analysis software ATLAS.TI V.7. The initial codingframework was based on key themes reflected in theinterview guide, participants’ accounts and fieldnotes.Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191 3Open AccessMore conceptually driven substantive codes (eg, trust,discrimination, control over sex work transactions) werethen applied. Verbatim narratives are reported usingpseudonyms assumed by sex workers to ensure anonym-ity. Longitudinal quantitative data on prevalence ofworkplace physical and sexual violence among sexworkers from the AESHA cohort were analysed by two8-month time periods (prepolicy, 1 May–31 December2012 vs postpolicy implementation, 1 January–31 August2013). Analysis was conducted using SAS statistical soft-ware V.9.2 and restricted to sex workers in AESHA whosolicited and/or serviced clients on the street.Descriptive frequencies and bivariate analyses were ana-lysed to test for statistical significance by time period ofVPD policy implementation (prepolicy vs postpolicy)and reported using ORs, 95% CIs and p values.RESULTSSample characteristicsThe sample for semistructured interviews included 26cisgender and 5 transgender women who were sexworkers (total n=31). The mean age of participants was38 years (range 24–53). Overall, 21 identified asCaucasian, 8 were of Aboriginal ancestry and 2 partici-pants were of other visible minorities. All participantshad experience with street solicitation. The majority(77%, n=24) reported street solicitation as their primaryway of connecting with clients, while others (23%, n=7)primarily used phone/text solicitation to connect withclients. Just over half (55%, n=17) primarily servicedclients in vehicles or outdoor public spaces, while 45%(n=14) primarily serviced clients in informal indoorvenues (eg, hotels, client’s place or their home).Sex workers’ experiences with new sex work enforcementpolicySex workers’ narratives and ethnographic observationsindicated that while police sustained a high level of visi-bility, they eased charging or arresting sex workers andshowed increased concern for their safety. Most sexworkers experienced a gradual change in policing over anumber of years rather than an abrupt change inpolicing with the publication of new sex work enforce-ment policy in January 2013. Some women felt that theywere interacting less with police as long as they solicitedclients in two separate areas of the city that function asde facto sex work tolerance zones.There’s more [police] presence. There’s not very manymore interactions. Before the interactions were alwaysthere. They’d come and pull you right outta car and, likepush you over. They’d get away with it back then. Youknow. But now it’s like they don’t, interact.—Anna, transgender woman sex workerThe vast majority of participants, regardless of gender,ethnicity and primary place of solicitation, reported thattheir interactions with police when soliciting sex workclients are more positive and generally focus on theirsafety.Every time they pull you over it’s strictly to ask you howyou’re doing, how things are. If there’s any bad dates youwant to report.—Fiona, cisgender woman sex workerWhile participants in this study viewed this change aspositive, the continued police enforcement of clientsseverely limited any positive impact of this change ontheir overall working conditions, risks for violence, abuseor negotiation of sexual risk reduction with clients.Continued police enforcement of sex buyers (clients)Sex workers’ narratives indicated that while police toler-ated sex work-related activities in two separate de factosex work zones, clients continued to be at risk of policescrutiny. Indeed, according to official police statistics sexwork-related criminal code offences rose from anall-time low of 47 in 2012 to 71 in 2013 (see figure 1).36This represents a 51% increase in prostitution-relatedoffences since the announcement of the VPD sex workenforcement guidelines in January 2013.Unfortunately, no statistics are available regarding theproportion of sex workers versus clients who werecharged. However, participants’ accounts indicate thatthe 51% rise in prostitution-related offences likelyreflects an increase of enforcement efforts targetingclients, as the majority of sex workers felt that theirclients were currently the main targets of police (consist-ent with messaging on the VPD website).34I think the Johns or clients that I have probably worrythe most about police.—Melissa, cisgender woman sex worker[Clients] do get stopped. A couple of my regulars they’vebeen chased off the street, they’re not allowed to comedowntown anymore. Down here they’re bad for that.I guess, it’s more so not the girls they go after—it’s the guys.—Maria, cisgender woman sex workerMost sex workers reported that clients are at risk ofbeing pulled over by police even before actuallyFigure 1 Prostitution-related criminal code offencesVancouver 2010–2013 (Vancouver Police Department).4 Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191Open Accessnegotiating a sex work transaction by circling aroundknown sex work areas. However, sex workers’ narrativesindicated that the riskiest time for attracting policeattention was the moment when women entered thevehicle of a prospective client. In some cases, policeused non-prostitution-related charges (eg, traffic viola-tions) as a means to pull over the vehicle and targetclients. Women expressed that while they used to be themain target of police, the recent experiences generallyended with the police allowing sex workers to leave,often without checking for outstanding warrants. Clientswere being detained by police, and issued either awarning or a fine.Right now when they [police] pull you over they let you,the girl go, keep the guy. Before they would separate youand then make a big investigation. Try to catch you inlies or intimidate you and make you nervous and try tosay you can get more charges.—Ruth, transgender woman sex workerOne of my regulars, they gave him a five-hundred dollardisturbing the peace ticket. And they didn’t run myname through. They just come out of nowhere, right?[Yeah, was it just for you getting in the car?] Yeah, I guessthat was just the punishment, you know what I mean? So,I saw the guy a few times afterwards and he was saying hewas going to fight and wanted me to be a witness andthen I guess he thought afterwards, geez no. He told mehe paid it online, I guess he has a family and that and hejust wanted it to go away.—Jessica, cisgender woman sex workerCriminalisation of clients: limited effect on deterrenceof sex workSex workers reported that when police target clients,some clients are deterred from purchasing sex on thestreet.No one will pull over if there’s a car, a police car nearyou. It’s, like, if they see the lights they’ll disappear. Youcan see the difference in traffic. They’re just gone.—Selina, transgender woman sex workerSome sex workers, however, felt that rather than pre-venting clients from purchasing sex, police presenceresulted in potential clients seeking out sex workers in adifferent area of the city.Once the guy that’s looking for a woman sees a cop, inthe neighbourhood, he’s scared. So he’ll go to anotherneighbourhood and find another woman somewhere.—Rebecca, cisgender woman sex workerFor participants in this study, the reality of living inpoverty and marginalisation often combined with illicitsubstance use meant that even when police targetclients, sex workers report that they continue to work forthe obvious reason of earning an income. Ethnographicobservation and sex workers’ narratives indicated thatpolice enforcement of clients had no effect on deterringwomen from engaging in street-based sex work (box 1).Indeed, for many participants the enforcement ofclients forced them to spend longer hours on the streetto earn an income. Thus, contrary to the objectives ofcriminalising clients, impeding sex workers’ ability toengage with potential clients did not result in less street-based sex work for these women. Instead, having accessto fewer clients meant it was harder to earn an incomeand forced sex workers to accept clients or services (eg,sex without a condom) that they would otherwise rejectdue to safety concerns; this directly increased risks forphysical and sexual violence and poor health, includingHIV/STIs.Criminalisation of clients: severely limits sex workers’safety strategiesOur findings indicate that criminalisation and policingstrategies that target clients reproduce the harmscreated by broader criminalisation of sex work. Analysesof prevalence of workplace physical and sexual violenceagainst street-based sex workers in Vancouver indicatedno statistically significant change in violence rates follow-ing policy implementation (OR=1.05, 95% CI 0.70 to1.58; p=0.804). Specifically, in the 8-month period post-policy implementation, 24.6% (58/236) of sex workersexperienced work-related physical and sexual violenceBox 1 Criminalisation of clients: limited effect on deter-rence of sex workSex worker voices:While they’re going around chasing johns away from pulling upbeside you, I have to stay out for longer […] Whereas if weweren’t harassed we would be able to be more choosy as towhere we get in, who we get in with you know what I mean?Because of being so cold and being harassed I got into a carwhere I normally wouldn’t have. The guy didn’t look at my faceright away. And I just hopped in cause I was cold and tired ofstanding out there. And you know, he put something to mythroat. And I had to do it for nothing. Whereas I woulda madesure he looked at me, if I hadn’t been waiting out there so long.—Violet, cisgender woman sex workerIt pisses me off that they [the police] are there because basicallywhat it comes down to is the shortest time that I’m out there, theshorter I’m on the street and the better I’m paid. But you [police]stand out there and you fuck up my business and scare away mydates. The longer I’m out there my chances of getting sick, raped,robbed, beat up whatever are greater so.—Lisa, cisgender woman sex workerOf course, ‘cause no one’s [clients] going to stop with themthere. I’m not going to go home. So they’re [police] not reallydoing anything, they’re just keeping me out there longer. Really, ifthey would just leave me alone, I’d get a date and go home andthey wouldn’t see me. But that way I end up staying out there forhours ‘cause I’m not going home empty-handed so I don’t knowwhat they think they’re really achieving.—Charlene, cisgender woman sex workerKrüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191 5Open Access(as compared with 23.7% (65/275) interviewed in the8 months prepolicy in 2012), of whom 22% reportedphysical abuse and 14% had been raped postpolicyimplementation (compared with 19.3% and 15.6% pre-policy, respectively).Qualitative analysis of the sex workers’ narrativesreveal three key mechanisms by which criminalisationand police targeting of clients continued to severelyimpact sex workers’ ability to negotiate their workingconditions and transactions with clients, including pro-tections from violence and HIV/STIs.Inability to screen clients and negotiate terms of sexualtransactionsSex workers’ narratives emphasised that in the contextwhere clients continue to be police targets, it remains inthe clients’ and sex workers’ interest not to get pulledover by police. Therefore, sex workers continue to beforced to severely limit or forego screening of prospect-ive clients or negotiating the terms of sex work transac-tions (eg, fee, sexual services and condom use) beforegetting into a vehicle (box 2). In addition to entering aprospective client’s car swiftly, participants reported thatin order to reduce the risk of attracting police attention,potential clients point them to an alleyway away fromthe main street with limited lighting to allow them toenter the vehicle undetected by police (box 2). Policingof clients thus directly undermines sex workers’ ability toscreen potential clients including checking ‘bad date’sheets for past violent perpetrators, detecting possibleweapons or intoxication; and negotiating the terms of thesexual transactions, including where the date will takeplace, the fee and types of sexual services and use ofcondoms, before entering a vehicle. These practices ofscreening and negotiating the terms of transactions havebeen well documented as critical to sex workers’ abilityto control their health and safety, including protectionsfrom violence, abuse and HIV/STIs.15 17 19Prior to the VPD policy, police frequently engaged inundercover operations in order to target sex workersand their clients. This practice continues to shape sexwork transactions and, in the context of sustained crim-inalisation of clients, undercover operations negativelyaffect the ability of sex workers to screen their clients ornegotiate the terms of sexual transactions. Participants’accounts indicated that rather than trying to assess thesafety of entering a vehicle of a prospective client andnegotiating the terms of the transaction, the initial inter-action with a client is dictated by determining whetherthe sex worker is an undercover police officer. Thisusually involves the client and sex worker touching eachother, due to the belief that undercover police officersare not allowed to engage in bodily contact withoutidentifying themselves as police.Normally when you get picked up, you go: Are you acop? No, are you? Nope. Prove it. And you, touch eachother just to make sure, right? ‘Cause cops can’t do that.So that’s the rule, if you’re undercover you can’t touchsomeone. Normally, a guy’ll touch my boob, I’ll touch hiscrotch. Or he’ll touch my crotch, I’ll touch his, right?That’s just to verify okay, you’re not a cop, right?—Martha, cisgender woman sex workerDisplacement to isolated areasSex workers’ accounts further indicated that in thecontext of continued criminalisation of clients, manyclients demand on engaging in sex work transactionsaway from known sex work areas where there is heigh-tened police presence. Participants reported that beingalone with clients in often unknown, secluded, industrialareas where there is little chance for help puts women atincreased risk of violence and rape and reduces theirability to negotiate the transaction on their terms, elevat-ing their risks for client condom refusal and thus HIV/STIs (box 3).Inability to access police protectionsThe main objective of the police enforcement guidelinesis to foster more trusting relationships between sexworkers and police and prioritise the safety of sexworkers in any police interactions. A striking feature ofmany sex workers’ accounts was that police inquiringabout their safety was perceived as a nuisance at best,and a form of police harassment at worst. In a contextwhere clients continue to be police enforcement targets,Box 2 Criminalisation of clients: severely limits sexworkers’ safety strategiesSex worker voices:Well, usually I try to hop in the car right away, right? ‘Cause Idon’t want to get seen talking, in case a cop drives by or some-thing. […] I’ll hop in and then we can like negotiate and talk, youknow? First I like to make sure that nobody’s around or followingor anything.—Maria, cisgender woman sex workerTo avoid police they [clients] drive by couple times and theypoint. They point at like a place where nobody’s driving by. Sothey point and that means to go follow them with the vehicle andthen they’ll stop […] They go somewhere different in an alley orsomething. They just leave like the window open and then youjust, get in. [But would you talk to them first?] Um no well whenthey’re trying to avoid police like that you just get into the vehicle,right.—Jane, transgender woman sex workerSometimes the guy will drive up and just sort of wave or point togo down the alley or something like that somewhere else were hecan pick me up. [How does that affect your safety?] You neverknow who it is right? And you can’t really see his face, can’treally see anything they could have a gun in their hand or. Youknow what I mean they could be a little bit drunk or something ifyou can’t really see them very clearly, you know? And you don’tyou can’t say hi or whatever before you get in. You have to justhurry up before the cops come.—Laura, cisgender woman sex worker6 Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191Open Accesssex workers’ narratives indicated it is difficult for policeto fulfil their stated objective of prioritising the safety ofsex workers. Even conversations between sex workersand police can have a destabilising effect, as any policeinteractions may scare away clients and have the poten-tial to raise suspicion that a sex worker might be anundercover police officer (box 4).Similarly, an important aspect of sex workers’ safety isthe ability to report theft, violence and sexual harassmentto police. Currently, however, the majority of sex workersvoiced reservations about reporting such incidents topolice. Many sex workers, drawing on historic discrimin-ation and maltreatment by police, doubted that policewould take their complaints seriously and voiced that thecontinued criminalisation of clients constituted a signifi-cant barrier to reporting violence to police as any infor-mation about where they work could be used to refineenforcement strategies targeting clients.DISCUSSIONThese findings suggest that criminalisation and policingstrategies that target clients reproduce the harmscreated by the criminalisation of sex work, in particular,risks for violence and abuse. Contrary to the goal ofcriminalising clients, our findings suggest that thisapproach has limited to no effect on preventing street-based sex work and did not reduce the prevalence ofsex work-related violence. Our analysis provides strongempirical evidence of the lived experience of sexworkers indicating that the continued criminalisationand policing of clients, even when sex workers are nolonger police targets, profoundly impacted sex workers’ability to negotiate their working conditions and healthand safety. Collectively, this research suggests that dis-placement to isolated areas and inability to screenclients or negotiate the terms of sexual transactions dir-ectly reduced sex workers’ ability to refuse unwantedclients or services (eg, sex without a condom), therebyincreasing risks for physical and sexual violence andHIV/STIs. In addition, despite improved relationsbetween sex workers and police, continued police target-ing of clients created mistrust of police and severelylimited sex workers’ ability to access police protections.In a legal environment where clients remain thetarget of enforcement, our findings indicate a sharedinterest of sex workers and clients to remain undetectedby police, forcing sex workers to rush or completelyforgo client screening, and pushing sex workers to workin secluded areas away from street lighting and otherpassersby. These findings reflect earlier epidemiologicaland social science research that have consistentlydemonstrated a direct correlation between criminalisa-tion and policing of street-based sex work and elevatedodds of physical violence and rape, as well as HIV/STIsthrough client condom refusal.5 6 10 11 15 18 This workhas identified screening of prospective clients as essen-tial to allowing sex workers to take safety precautions,including agreement on where the transaction will takeplace, checking ‘bad date’ reports describing theBox 3 Criminalisation of clients: displaces street-basedsex work to isolated areasSex worker voices:Clients worry [about police]. Like for me I don’t like goingoutside the neighborhood, right. Cause, you know what about ifthe guy turns out to be an asshole. […] That’s how I do loosedates by not going where I’m supposed to cause they’re afraid ofcops. [So do you turn dates down sometimes?] Yeah sometimesbut not all the time cause when I’m I’m really in need of money Iwill maybe try and go. But then I just try and get a good feel ofthem first.—Jane, transgender woman sex workerClients are worried about police. To avoid police they wannamove to a different area. I don’t want to go out of my zone right.[…] Once you get out there, like you know their turf so it’s harderfor me cause it’s their comfort zone so they act differently, youknow what I mean. Yeah it never ends up good.—Sandra, cisgender woman sex workerWe try to get away from the area as quick as possible. You know.So that we’re not in the area. Right. The farther away you getfrom [name of sex work stroll], the better it is. You’re not gonnaget pulled over right? I’m just a little nervous as it’s so quietdown there by [industrial area].—Violet, cisgender woman sex workerBox 4 Criminalisation of clients: prevents access to policeprotectionsSex worker voices:Destabilising effect of police safety checksIt’s a drag, you know? I’m out there to make money, not wastetwenty minutes talking to them [police]. And then I’m talking tothem and half the dates that see me talking to them now thinkmaybe I’m a cop, so they don’t wanna stop, now they know thecops are around, they don’t wanna stop, or they wonder what I’vedone to attract the cops so they don’t wanna stop, it’s just ahassle, you know?—Charlene, cisgender woman sex workerIf the clients see you talking to the cops then they don’t pick youup. [When police talk to me] they’re respectful but they know thatthey’re wasting my time so. They can do whatever they want.They’re fucking up everything.—Selina, transgender woman sex workerReporting violence to policeNo I would never go to the cops [to report violence]. Because itmakes it look like, we shouldn’t be out there like we can’t takecare of ourselves. I feel like if I went and reported some of thesethings that it might do more harm to the working profession thando good. So I don’t do that. Basically we have to fend for our-selves. They don’t really like us to begin with.—Rose, cisgender woman sex workerI’ve needed the police’s help with bad dates and they’ve doneabsolutely nothing. The fact that it’s not legalized you kinda can’tdo it, you know.—Charlene, cisgender woman sex workerKrüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191 7Open Accesspersonal characteristics and/or vehicle of known violentperpetrators and checking for the presence of weaponsand intoxication.12 In addition to screening, negotiatingthe terms of sexual transactions with clients beforeentering the vehicle, including the fee and types ofsexual services, remains critical for sex workers to negoti-ate the terms of their work, and avoid risky sexualencounters (eg, unprotected sex). Without the oppor-tunity to screen clients or safely negotiate the terms ofsexual services, research has shown that sex workers faceincreased risks of violence, abuse and HIV/STIs.15 17 18 37 38 Our findings resonate with evaluationsfrom Sweden that reported that since the implementa-tion of the law that criminalises clients, there had beenan increase in violence experienced by sex workers,which was linked to greater risk taking in client selectiondue to the necessity of rushed negotiation with potentialclients.28 29Police undercover operations further reduce the safetyof sex workers as initial interactions with clients focus ondetermining that sex workers are not undercover policeofficers, rather than allowing time to negotiate thedetails of the transaction, including condom use, type ofservice and price. The negative impact of undercoverpolice operations on the safety and health of sexworkers is of note as it is one of the main enforcementstrategies available to police in a context where clientsare criminalised. Sex workers also described how policeused other non-prostitution-related offences (eg, admin-istrative laws such as traffic violations, public nuisance)to target sex workers and clients.The results of this study further highlight that in acontext where sex buyers are criminalised, sex workerscontinue to be displaced, as many clients insist onengaging in sex work transactions away from police scru-tiny. Being displaced to unknown, secluded, industrialareas where there is little chance of receiving help whenneeded is linked to increased risk of violence and rapeand reduces sex workers’ ability to negotiate the transac-tion on their terms, including condom use.15 17 37 38Evidence from Canada and globally has consistentlyshown that criminalisation of sex work prevents sexworkers from accessing police protection, wherebypolice become adversaries as opposed to safety mechan-isms.6 9 10 22 29 A clear example is the case of the detri-mentally flawed police investigation of the serial murderof the missing women in Vancouver, Canada; wherecriminalisation and historic discrimination by policewere found to be key factors in putting police in anadversarial relationship with sex workers.32 In additionto the deeply engrained stigma of sex work and the his-toric police discrimination of sex workers, our findingsindicate that when sex work clients are police enforce-ment targets, many sex workers remain reluctant to seekpolice protection. Sex workers worry about disclosingdetails of how they operate and where they work for fearpolice may use this information to refine their enforce-ment strategies that target sex work clients. This studyalso identified that in a context of continued policeenforcement of sex work clients, even conversations withpolice about safety can have a destabilising effect, as anypolice interactions scare away clients and have thepotential to raise suspicion that a sex worker might bean undercover police officer or a police informant. Thispolicing practice deters women from interacting withpolice and undermines the main objective of the VPDpolicing guidelines, which is to prioritise the safety ofsex workers. In addition to scaring away potential clients,and thus potentially reducing the income women relyon, being labelled as a police informant can place awoman at the bottom of street hierarchy and may placeher at severe risk for violence.While rhetorically powerful and politically appealing,there is a fundamental conceptual inconsistency in pol-icies that criminalise clients and purport to prioritise thesafety of sex workers. In its original incarnation, themodel of criminalising clients in Sweden was notdesigned to increase the safety of women in sex work;rather its goal was to eradicate prostitution and increasethe safety of women who exit sex work. Indeed, inSweden, the government explicitly condoned theincreased risks that marginalised sex workers wereexposed to by arguing that any adverse effects onwomen who remain in sex work were outweighed by themessage of the law that prostitution is not tolerated.28Our findings indicate that policies that criminaliseclients are, in practice, not reconciled with policies thataim to prioritise the safety of sex workers, such as out-lined in VPD sex work enforcement guidelines. Indeed,the findings of our study indicate that despite policeefforts to prioritise the safety of sex workers, whenclients remain enforcement targets, sex workers con-tinue to be at increased risk for physical and sexual vio-lence and perceive police concern for their safety as aform of nuisance and harassment.Street-involved sex workers, those living in poverty,Aboriginal sex workers and transgender sex workers havehistorically been exposed most directly to the negativeeffects of restrictive policing and criminalised sex worklaws.14 15 28 Evidence from Sweden indicates that crimina-lising clients negatively affected the working conditionsand safety of all segments of sex workers by furtherpushing them underground. However, marginalised sexworkers who solicit and/or service on the street were mostnegatively impacted by the criminalisation of clients, asthey may not have the resources to reduce police scrutinyby advertising online, or be contacted by phone.28 Owingto a less-developed welfare system in Canada, and thelarger population of street-based sex workers comparedwith Sweden, the negative impact of demand criminalisa-tion on sex workers’ health and safety will likely be evenmore pronounced in the Canadian context.The very existence of specific laws to regulate sex workspeaks of the stigma associated with sex work and thelink between sex work legislation and morality.39 InCanada, as in most settings globally, there are already8 Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191Open Accesslaws in place for targeting various forms of exploitationand nuisance that may arise in the context of sex work,such as public disturbance, indecent exhibition, coer-cion, sexual assault, trafficking persons, extortion andkidnapping. As such, given the negative impact of crimi-nalised sex work laws and enforcement practices, ourfindings lend further support to calls for the full decrim-inalisation of sex work in Canada, consistent with inter-national guidelines by global policy bodies.1 29New Zealand and parts of Australia have decriminalisedsex work. In New Zealand, workplace health and safetystandards have been established in consultation with sexworkers, and sex workers can bring employment com-plaints to governing bodies.27 The New ZealandProstitution Reform Act enacted in 2003 treats sex work asany other business, regulating its commercial practicethrough standard employment health and safety regula-tions, regulating the location of commercial sex establish-ments through zoning by-laws and specifying the healthand safety obligations of managers and workers.39Although decriminalisation is by no means a panacea,there is significant evidence to suggest that in NewZealand it has created improved working conditions forsex workers, including increased ability to report violenceto police.40 The removal of criminalised and enforcement-based approaches to sex work will also help to supportaccess and implementation of other health and socialinterventions not currently available to the most crimina-lised street-involved sex workers, such as safer indoor workand housing spaces, integrated health and social welfaresupports, substance-use prevention and treatment andopportunities for alternative employment for those sexworkers who choose to transition out of sex work.This study has limitations. The lived experiences ofparticipants represented in this study reflectstreet-involved sex workers living in poverty and may notbe representative of the experiences of sex workers inother segments of the industry. However, given that evi-dence has consistently shown that criminalisation andpolicing disproportionately target street-based sexworkers, we feel these narratives provide critical evi-dence of the health and safety harms of such a policy.In summary, this study suggests that enforcement strat-egies that target sex workers’ clients reproduce theharms related to criminalised and quasi-criminalisedapproaches to the regulation of sex work. This empiricalresearch clearly demonstrates that continued criminalisa-tion and policing of clients, even in a context where sexworkers no longer represent police targets, did notreduce the prevalence of sex work-related violence andprofoundly impacted sex workers’ ability to negotiatetheir working conditions, health and safety, includingprotections from violence, abuse and HIV/STIs. Sexworkers were displaced to isolated areas with few protec-tions from violence and abuse, were forced to rush orforgo screening clients and negotiating the terms oftransactions (eg, fee and condom use) and agree toclients or sexual services they would otherwise refuse andwere unable to access police protections. The results alsohighlight the critical role of sex workers’ lived experi-ences in any evidence-based policy making in Canadaand globally. Two decades of failures of prostitution lawsin Canada stemmed from failure of consecutive govern-ments to listen to strong evidence by sex workers, aca-demics and human rights experts that the laws werecreating and exacerbating devastating harms to sexworkers’ safety, health and human rights, including vio-lence, abuse and murder. In sum, this study raises seriousquestions about legislative approaches that criminaliseclients and suggests that ‘demand criminalisation’ risksreproducing the devastating harms to health safety andhuman rights created by the criminalisation of sex work.Author affiliations1Gender and Sexual Health Initiative, British Columbia Centre for Excellence inHIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada2Pivot Legal Society, Vancouver, British Columbia, Canada3Sex Workers United Against Violence, Vancouver, British Columbia, Canada4Department of Medicine, University of British Columbia, Vancouver, BritishColumbia, Canada5Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS,St. Paul’s Hospital, Vancouver, British ColumbiaAcknowledgements The authors would like to thank all the women whocontributed their time and expertise to this project, as well as research,community partners and advisory board members. They wish to acknowledgePeter Vann, Gina Willis and Jennifer Morris for their research andadministrative support.Contributors KS is the principal investigator and senior author of the studyand takes full responsibility for the integrity of the study procedures and datacollection, management and analysis. AK, KP, JC and KS conceptualised thisstudy and AK oversaw the field team carrying out the study. AK and CTconducted the interviews. AK and JC conducted the ethnographic observation.AK analysed the data using Atlas software, wrote the original draft of thearticle and incorporated feedback from all coauthors. KP, CT, JC, LB, SA, DB,TK, JSM and KS provided content expertise and critical feedback on theanalyses and interpretation. All authors read and approved the finalmanuscript.Funding This research was supported by operating grants from the USNational Institutes of Health (R01DA033147 and R01DA028648).Competing interests KS is partially supported by US National Institutes ofHealth (R01DA028648), Canadian Institutes of Health Research and MichaelSmith Foundation for Health Research. JSM is supported by the BritishColumbia Ministry of Health and by the US National Institutes of Health(R01DA036307).Ethics approval Providence Healthcare/University of British of ColombiaResearch Ethics Board.Provenance and peer review Not commissioned; externally peer reviewed.Data sharing statement No additional data are available.Open Access This is an Open Access article distributed in accordance withthe terms of the Creative Commons Attribution (CC BY 4.0) license, whichpermits others to distribute, remix, adapt and build upon this work, forcommercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/REFERENCES1. WHO, UNAIDS, UNICEF. Global HIV/AIDS response: epidemic updateand health sector progress towards universal access. Geneva: WorldHealth Organization, 2011. http://whqlibdoc.who.int/publications/2011/9789241502986_eng.pdf?ua (accessed 7 Feb 2014).Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191 9Open Access2. Rhodes T, Simic M, Baros S, et al. Police violence and sexual riskamong female and transvestite sex workers in Serbia: qualitativestudy. BMJ 2008;337:a811.3. Simic ́ M, Rhodes T. Violence, dignity and HIV vulnerability: streetsex work in Serbia. Sociol Health Illn 2009;31:1–16.4. Gruskin S, Williams Pierce G, Ferguson L. Realigning governmentaction with public health evidence: the legal and policy environmentaffecting sex work and HIV in Asia. Cult Health Sex 2013;16:14–29.5. Platt L, Jolley E, Rhodes T, et al. Factors mediating HIV risk amongfemale sex workers in Europe: a systematic review and ecologicalanalysis. BMJ 2013;3:e002836.6. Shannon K, Csete J. Violence, condom negotiation, and HIV/STIrisk among sex workers. JAMA 2010;304:573–74.7. Platt L, Rhodes T, Judd A, et al. Effects of sex work on theprevalence of syphilis among injection drug users in 3 Russiancities. Am J Public Health 2007;97:478.8. Shannon K, Montaner JG. The politics and policies of HIVprevention in sex work. Lancet Infect Dis 2012;12:500.9. Okal J, Chersich MF, Tsui S, et al. Sexual and physical violenceagainst female sex workers in Kenya: a qualitative enquiry. AIDSCare 2011;23:612–18.10. Shannon K, Kerr T, Allinott S, et al. Social and structural violenceand power relations in mitigating HIV risk of drug-using women insurvival sex work. Soc Sci Med 2008;66:911–21.11. Rekart ML. Sex-work harm reduction. Lancet 2006;366:2123–34.12. Sanders T. The risks of street prostitution: punters, police andprotesters. Urban Stud 2004;41:1703–17.13. Lowman J. Violence and the outlaw status of (street) prostitution inCanada. Violence Against Women 2000;6:987–1011.14. Sanders T, Campbell R. Designing out vulnerability, building in respect:violence, safety and sex work policy. Br J Sociol 2007;58:1–19.15. Shannon K, Strathdee SA, Shoveller J, et al. Structural andenvironmental barriers to condom use negotiation with clientsamong female sex workers: implications for HIV-preventionstrategies and policy. Am J Public Health 2009;99:659–65.16. Maher L, Mooney-Somers J, Phlong P, et al. Selling sex in unsafespaces: sex work risk environments in Phnom Penh, Cambodia.Harm Reduct J 2011;8:30.17. Krüsi A, Chettiar J, Ridgway A, et al. Negotiating safety and sexualrisk reduction with clients in unsanctioned safer indoor sex workenvironments: a qualitative study. Am J Public Health 2012:1154–9.18. Deering KN, Lyons T, Feng CX, et al. Client demands for unsafesex: the socioeconomic risk environment for HIV among street andoff-street sex workers. JAIDS 2013;63:522–31.19. Shannon K, Kerr T, Strathdee SA, et al. Prevalence and structuralcorrelates of gender based violence among a prospective cohort offemale sex workers. BMJ 2009;339:442–5.20. Lippman SA, Donini A, Diaz J, et al. Social-environmental factorsand protective sexual behavior among sex workers: the Encontrosintervention in Brazil. Am J Public Health 2010;100:S216–23.21. Kerrigan D, Ellen JM, Moreno L, et al. Environmental-structural factorssignificantly associated with consistent condom use among female sexworkers in the Dominican Republic. AIDS 2003;17:415–23.22. Richter ML, Chersich MF, Scorgie F, et al. Sex work and the 2010FIFA World Cup: time for public health imperatives to prevail. GlobalHealth 2010;6:1.23. Lazarus L, Deering KN, Nabess R, et al. Occupational stigma as aprimary barrier to health care for street-based sex workers inCanada. Cult Health Sex 2012;14:139–50.24. Boynton P, Cusick L. Sex workers to pay the price: UK plans to cutstreet prostitution will threaten sex workers’ health. BMJ2006;332:190.25. Scorgie F, Nakato D, Harper E, et al. We are despised in thehospitals: sex workers’ experiences of accessing health care in fourAfrican countries. Cult Health Sex 2013;15:450–65.26. Oppenheim M. MEPs vote to criminalise buying sex. The Guardian26 February 2014.27. Goodyear M, Weitzer R. International trends in the control of sexualservices. In: Dewey S, Kelly P, eds. Policing pleasure: sex work,policy and the state in global perspective. New York: New YorkUniversity Press, 2011:16–30.28. Scoular J. Criminalizing ‘punters’: evaluating the Swedish positionon prostitution. J Soc Welf Fam Law 2004;26:195–210.29. Global Commission on HIV and the Law. HIV and the law: risks,rights, & health, 2012. http://www.undp.org/content/dam/undp/library/HIV-AIDS/GovernanceofHIVResponses/Commissionsreportfinal-EN.pdf (accessed 4 Feb 2014).30. Canada Supreme Court. Decision, Canada (attorney general) vs.Bedford. Ottawa: Supreme Court of Canada, 2013. http://scc-csc.lexum.com/decisia-scc-csc/scc-csc/scc-csc/en/item/13389/index.do(accessed 3 Feb 2014).31. Crawford A. Peter MacKay faces balancing act with justice agenda,court rulings. Canadian Broadcasting Corporatio. 27 January 2014.http://www.cbc.ca/news/politics/peter-mackay-faces-balancing-act-with-justice-agenda-court-rulings-1.2511220 (accessed 2 Mar 2014).32. Oppal W. Forsaken: the report on the missing and murdered womencommission of inquiry. British Columbia, 2012. http://www.ag.gov.bc.ca/public_inquiries/docs/Forsaken-ES.pdf (accessed 3 Mar 2014).33. Vancouver Police Department. Sex work enforcement guidelines,2013. http://vancouver.ca/police/assets/pdf/reports-policies/sex-enforcement-guidelines.pdf (accessed 7 Jan 2014).34. Vancouver Police Department. Counter explotation unit. http://vancouver.ca/police/organization/investigation/investigative-services/special-investigation/vice.html (accessed 7 Jan 2014).35. Shannon K, Bright V, Allinott S, et al. Community-based HIVprevention research among substance-using women in survival sexwork: the Maka Project Partnership. Harm Reduct J 2007;4:20.36. Vancouver Police Department. Statistical reports by district and citytotals. https://vancouver.ca/police/Planning/StatsDistrict/2013/2012–2013YTD.pdf (accessed 7 Jan 2014).37. Decker MR, McCauley HL, Phuengsamran D, et al. Violencevictimisation, sexual risk and sexually transmitted infectionsymptoms among female sex workers in Thailand. Sex TransmInfect 2010;86:236–40.38. Decker MR, Wirtz AL, Baral SD, et al. Injection drug use, sexual risk,violence and STI/HIV among Moscow female sex workers. SexTransm Infect 2012;88:278–83.39. Bruckert C, Hannem S. Rethinking the prostitution debates:transcending structural stigma in systemic responses to sex work.Can J Law Soc 2013;28:43–63.40. Abel G, Fitzgerald L, Brunton C. The impact of decriminalisation onthe number of sex workers in New Zealand. J Soc Policy2009;38:515–31.10 Krüsi A, Pacey K, Bird L, et al. BMJ Open 2014;4:e005191. doi:10.1136/bmjopen-2014-005191Open Access


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