Policy BRIEFING

ISSUE 101 • SEPTEMBER 2015

Developing More Effective
Strategies for Sex Work,
Law and Poverty
The welfare of female sex workers in low-income countries has attracted
significant attention in recent years. In line with human rights and development
goals, advocacy focuses on decriminalisation of sex work, attaining economic
rights, ending violence and improving sexual and reproductive health. Recent
studies by the IDS Sexuality, Poverty and Law programme have highlighted many
of these issues and placed them within the wider context and discussion around
sexuality and development. We call for further research and action in three
key areas, where evidence is needed to drive feasible, effective and measurable
initiatives that benefit sex workers, even in unfavourable legal, economic and
social conditions.
Understanding the impact of
economic empowerment
programmes
Research conducted in wealthy and poor
countries alike overwhelmingly supports
the assumption that poverty propels
women and girls into sex work and
renders sex workers more vulnerable to
discrimination, exploitation and illness.
Thus poverty alleviation programming
and policy have important roles to play
in both reducing the flow of women
and girls into the sex industry and in
strengthening sex workers’ economic
capacities and increasing access to goods
and services – in other words, ‘economic
empowerment’.
Many types of rehabilitation and
targeted economic empowerment
programmes (EEPs) for female sex
workers are operated in dozens of
countries by organisations concerned
with development, public health, gender
and, perhaps most frequently, faith.
Their methods vary but usually include
activities such as vocational skills building,
microcredit, social protection, income
generating activities, counselling and
saving cooperatives, among others.
Despite their prolific presence, little
information is available about the scale

“Despite
and impact of EEPs on outcomes such
as HIV or gender-based violence and
their prolific
data about cost, outcomes or scale are
presence, little
rare. Conceptual frameworks, policy
information is
overviews or clear maps of how and
available about
where programmes operate are also
lacking. In the absence of research
the scale and
about EEPs there is little technical
impact of EEPs
information and few tools to guide
on outcomes
best practice. This means that successes,
such as HIV or
suboptimal outcomes and failures of
gender-based
policies and programmes are not well
understood. It can also mean that adverse violence and
events associated with rehabilitation
data about
and economic empowerment not
cost, outcomes
systematically observed and documented,
and opportunities to improve and expand or scale are
rare.”
effective strategies are missed.
Sex workers are often encouraged to take part in
economic empowerment programmes to help them
exit sex work by requiring that they give up sex work
while they learn new skills like hairdressing and
sewing. Some of these programmes work but the
majority of them fail sex workers to such an extent
it is hard to imagine why such programmes are still
considered as acceptable by some.
(The Global Network of Sex Work Projects)
www.nswp.org/news/when-economicempowerment-programmes-fail-sex-workers

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Promoting legal recognition
The limited research available about sex work
and citizenship indicates that rules that govern
administrative matters and confer status
on people as citizens, workers and family
members have a significant effect on the
circumstances in which sex is bought and sold
and how sex workers live. Lack of citizenship
or legal personhood, which is usually
experienced as the absence of identification
documents, appears to be associated with
poor outcomes. If this is true, it points to
opportunities to change policy and practices
that could significantly improve the ability of
sex workers to work in the safest possible
circumstances; to house and educate their
children; and to avoid violence, exploitation
and discrimination.
Birth registration is usually the first step in
gaining recognition of legal personhood.
It is a crucial gateway to other forms of
legal recognition and citizenship, including:
passports, marriage licenses, naturalisation
and enrolment in taxation, electoral and
other civic registers. Perhaps the most
recognisable example of adults lacking legal
personhood is undocumented migrants. In
some places identity is recognised by local
government and it is lost if the person
moves to another place within the same
country. Where people do not enjoy the
recognition of law they are vulnerable to
inappropriate law enforcement and typically
do not have access to health care, social
services, accommodation, financial services,
communications, humanitarian aid and
education. This has a particular impact on sex
workers ‘without papers’ who must use other
strategies to obtain goods and services, or
do without them. Thus poverty, vulnerability,
exploitation and illness are exacerbated by
lack of legal status, which frequently extends
to sex workers’ children who are, in turn,
denied vital resources and incentivised to
enter the sex industry.
Surprisingly, in this context, associations
between lack of legal personhood and
health and welfare outcomes for sex workers
have barely been studied. Nevertheless the
value of gaining legal recognition has been
identified by some frontline services that

help sex workers to obtain the identification
documents needed to establish legal
personhood. Because people must complete
application forms and prove, for example,
that they have a formal residential address or
work in the formal economy it is frequently
a difficult process, especially for sex workers
who are not literate, are mobile or live in
informal settlements.
As a result of an IDS Sexuality, Poverty
and Law Evidence Report on sex work and
poverty in Ethiopia, a non-governmental
organisation (NGO) that operated several
drop-in centres for sex workers throughout
the country began helping users of its services
to apply for them. The director of the NGO
reported that identity documents have been
obtained for many sex workers with some
positive outcomes. He said that the requests
for identification documents had been
received more favourably by authorities than
anticipated. Evidence like this suggests that
ensuring sex workers legal personhood is a
politically feasible strategy and could effectively
address sex workers’ vulnerability in lowincome countries.

Planning for the impact of biomedical
HIV prevention
As a result of scientific advances the focus of
HIV programmes is shifting from education,
condoms and the treatment of sexually
transmitted diseases to preventing HIV
transmission by providing anti-retroviral
medication (ARVs). These medications prevent
transmission in two ways:
1.	When used as treatment in HIV-positive
people ARVs reduce the presence of
the virus to a level where it cannot be
transmitted. This is known as Treatment as
Prevention (TasP).
2.	When taken by HIV-negative people
ARVs significantly reduce the chances of
contracting HIV through sex.
While scientific developments have the
potential to reduce HIV infection globally or
even end the epidemic, they raise significant
challenges for female sex workers. As well
as affecting how health services are provided

DEVELOPING MORE EFFECTIVE STRATEGIES FOR SEX WORK, LAW AND POVERTY ISSUE 101 • SEPTEMBER 2015	

“Where people
do not enjoy
the recognition
of law they are
vulnerable to
inappropriate
law enforcement
and typically do
not have access
to health care,
social services,
accommodation,
financial services,
communications,
humanitarian aid
and education.”

to female sex workers they will impact on
the resourcing of social programming and
advocacy.
A key challenge is how to ensure that
universal HIV testing of sex workers does
not reduce confidentiality or increase
discrimination and abuse. Another challenge
is that because pre-exposure prophylaxis
(PrEP) is not 100 per cent effective against
HIV and does not protect against sexually
transmitted infections (STIs) or pregnancy it
must be used with condoms, not instead of
them. But in many settings it is likely that
sex workers will not be able to continue to
insist on condom use as demand rises for a
product perceived as making ‘flesh-to-flesh’
sex safe. Where that occurs HIV risk will
remain or increase (depending on numbers
of clients and prevalence of untreated HIV
in sexual partners) and STIs, hepatitis and
unplanned pregnancies would increase.
Hence, new HIV prevention has been dubbed
‘combination prevention’ to encourage sex
workers to both take PrEP and refuse sex
without a condom. However, this is sure to
be difficult, particularly where clients and sex
business owners decide what methods are
used to protect sexual health rather than sex
workers.

“While scientific
developments
have the
potential to
reduce HIV
For sex workers to benefit from biomedical
infection globally
HIV prevention and treatment, strategies
or even end the
must be in place to avoid adverse events
epidemic, they
and human rights abuses. They must ensure
that medications are properly prescribed and
raise significant
adhered to and that STIs, HIV or unwanted
challenges for
pregnancies do not increase even in the most
female sex
vulnerable sex workers. To achieve this it is
workers.”
crucial that efforts continue on reducing
and mobile sex workers, those who live
in remote areas or lack legal personhood
and other groups of sex workers who are
unable or unwilling to access or manage
prescription medicine.

the factors that leave sex workers powerless
and obstruct current HIV programming –
discrimination, exclusion, cost, violence, loss
of livelihood, lack of nutrition and housing
and poor treatment by health-care workers.
This raises the question of how governments,
development agencies and NGOs can
reconfigure resources allocations to ensure
that work towards human rights, social and
economic goals that was previously funded
from HIV budgets continues and grows
despite the shift toward medicalised HIV
prevention.

Concerns have also arisen about drug
resistance and toxicity, meeting new
information needs and the cost of products.
Access to clinical services is also a key issue
since sex workers who take PrEP must
regularly access a qualified doctor who can
prescribe medicine and monitor its effects.
In contrast to condoms and education
which could be distributed freely by staff
with basic training, scaling up testing and
administering prescription medications
means that highly qualified service providers
will need to identify, track and retain large
populations of sex workers as patients.
This may be unrealistic where funds are
unavailable, where health systems are weak
and/or sex workers are excluded, and the
need to identify individuals raises ethical
challenges where the resources or will to
protect patients are lacking. Raising the
bar for individuals’ access to HIV prevention
has clear potential to leave behind migrant

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Policy recommendations
Decriminalise sex work
Amnesty International is the latest of dozens of respected human rights and health
organisations to join the consensus that sex work should be decriminalised because
criminal law forms the single greatest barrier to sex workers attaining justice and
dignity. Law reform is a primary recommendation because it plays a crucial role in
determining how effective any strategy can be. This means that until laws against
sex work are removed programmes and policies that are viable despite unfavourable
conditions must be identified and implemented.
Economic empowerment programmes
Policymakers, donors and implementers of EEPs need data and guidance to inform policy
and programming for sex workers that is ethical, effective and that significantly alleviates
poverty and its impacts on sex workers and their families. Next steps should include:
•	 Mapping existing economic empowerment programming.
•	 Identifying the evidence, and evidence gaps, around targeted poverty alleviation
strategies for sex workers.
•	 Conducting research in multiple sites to identify the impact of various methods
on multiple outcomes, including unintended consequences.
•	 Developing a conceptual framework, practical guidance and tools such as protocols
for measuring outcomes for sex workers of various ages and backgrounds.
Legal recognition
The notion that increasing sex workers’ legal recognition is a cost-effective and
politically feasible intervention that can improve sex workers’ economic, health and
social status should be tested by documenting existing interventions and conducting
research to explore correlations and associations between increased citizenship and
specific outcomes for sex workers and their families.
If it is proven that obtaining legal identification documents improves sex workers’
lives and reduces vulnerability, materials should be developed to encourage and
guide NGOs and governments to work cooperatively to implement action to
recognise sex workers’ legal personhood.
Biomedical HIV prevention and care
Resources should be made available to support independent research and advocacy
that aims to ensure that biomedical HIV care and prevention effectively reduces HIV
among sex workers without generating adverse consequences. This should include:
•	 A global review of the evidence on biomedical HIV prevention and care for
sex workers in low-income countries. The review should identify evidence and
evidence gaps; policy and programming that can best support biomedical HIV
treatment for sex workers; and any strategies that are being developed, or are in
place, to address potential barriers and reduce associated risks.
•	 Development of protocols for monitoring a broad set of outcomes of biomedical
HIV care and prevention for sex workers.
•	 Monitoring the impact of new approaches to HIV prevention on interventions that
aim to empower sex workers economically and socially. This information should be
used by development and public health agencies to ensure that effective work in
these areas is not undermined or reduced as a result of resources shifting toward
providing clinical HIV services.

Further reading
Bekker, L.; Johnson, L.; Cowan,
F.; Overs, C.; Besada, D.; Hillier,
S. and Cates, W. (2015)
‘Combination HIV Prevention
for Female Sex Workers: What
is the Evidence?’, The Lancet
Series on HIV and Sex Work
385: 9962
Global Network of Sex Work
Projects (2011) New Prevention
Technologies and their Implications
for Sex Workers, Briefing Paper
4, Global Network of Sex Work
Projects
Overs, C. (2014) Sex Workers,
Empowerment and Poverty
Alleviation in Ethiopia, IDS
Evidence Report 80, Brighton:
IDS
Overs, C. and Loff, B. (2013)
‘Towards a Legal Framework
that Promotes and Protects Sex
Workers’ Health’, Health and
Human Rights 15: 1

Credits
This IDS Policy Briefing was
written by Cheryl Overs,
Visiting Fellow at the Institute
of Development Studies, and
was edited by Carol Smithyes. It
was produced as part of the IDS
Sexuality, Poverty and Law
programme, supported with UK
Aid from the UK Department
for International Development.
The opinions expressed are
those of the author and do not
necessarily reflect the views of
IDS or the UK government’s
official policies.
Readers are encouraged to
quote and reproduce material
from issues of IDS Policy Briefings
in their own publication. IDS
requests due acknowledgement
and quotes to be referenced as
above.
AG Level 2 Output ID: 604
© Institute of Development Studies, 2015
ISSN 1479-974X

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IDS POLICY BRIEFING ISSUE 101 • SEPTEMBER 2015	

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