East London Project: a participatory mixed-method evaluation on how removing enforcement could affect sex workers' safety, health and access to services in East London

Conceptual framework

In the original study proposal, we drew on concepts used in public health and social science to understand how criminalisation and enforcement may interact with other social and structural factors to affect sex workers’ health. The ‘risk environment’ is an analytical tool that considers how different types of environments (physical, social, economic and political) and levels of environmental influence (micro and macro) shape risk. 24 First developed to analyse drug-related harms, this concept has been used to examine the contexts of HIV and violence experienced by sex workers. 3,25 Drawing on this concept, Shannon et al. 5 propose a structural determinants framework for sex workers’ vulnerability to HIV, depicting how factors at macro-structural (e.g. criminalisation, housing), community (e.g. access to sex worker organisations) and work environment (e.g. safety systems) levels interact with individual behaviours and vulnerabilities to affect risk. Our interdisciplinary collaborations expanded during the research, and as such we drew on a wide range of concepts across sociology and criminology, particularly to guide our qualitative analysis, including those of ‘social justice’,26,27 ‘social harms’,28 ‘necropolitics’29 and ‘assemblage theory’. 30 We describe and discuss these concepts as they relate to this research in the conceptual framework section of the main qualitative article. 31 In brief, we used the term ‘necropolitical assemblages’ to describe the interactions and tensions between police, immigration, (public) health and social welfare services (assemblages) that led to increasingly unsafe and precarious working and living conditions for sex workers in this context (necropolitics). We used the concept of restorative social justice27 – whereby excluded communities can, with appropriate resources, recognition and representation,26 claim justice and support ‘in and on their own terms, in the contexts of their lives’31 rather than through hostile systems – to analyse how sex workers navigated, responded to and organised against these harms. Below we provide more detail on how we drew on this conceptual literature during qualitative analyses (see Methodologies, Qualitative study).

Study context

Under current legislation in England, fines, civil and criminal measures penalise loitering, soliciting (sex workers seeking clients) and ‘kerb crawling’ (clients seeking sex workers) in public places. Working indoors with third parties, including with other sex workers, can also result in prosecution for keeping, managing or assisting in the management of a brothel. Contravention of associated criminal behaviour orders, community protection notices, dispersal orders or brothel-closure orders can result in fines and prison sentences. Sex workers also face enforcement from local authorities and immigration officers using laws relating to drugs, immigration, ‘anti-social behaviour’ (ASB) and public order. 32 In practice, levels of enforcement vary considerably between locations. Although some police forces continue to enforce against sex workers and their clients, others have previously adopted a non-enforcement approach, including in parts of Leeds and London. 33 In 2016, the UK Home Affairs Select Committee (HASC) recommended removing penalties for street sex work and working indoors with other people for safety. 34 They did not endorse either a model of decriminalisation or the criminalisation of the purchase of sex, citing the need for more evidence. Since the publication of the HASC report, updated National Police Chief Council guidance35,36 urges officers to prioritise the safety of sex workers over enforcement, but arrests and prosecutions of sex workers are still widely documented by sex worker rights and support organisations. Debates around sex work laws continue and are polarised. The 2018 call by an all-party parliamentary group to criminalise the purchase of sex with a view to ending demand for sex work was contested by sex worker rights organisations, other civil society groups and academics for marginalising sex workers further and failing to recognise the diversity of experience and identity within sex work. 37,38 Alongside international bodies, these organisations argue in favour of decriminalising sex work to reduce harms and rights violations against sex workers. 39–41

Sex worker support services have long been recognised as key to addressing the complex health and social care needs of this marginalised and dynamic population in the UK; internationally, the success of sex worker support services in halting early outbreaks of HIV, syphilis and tuberculosis among sex workers is evident. 42,43 Our previous London-based research44 demonstrated that these services remain as vital as ever to sex workers’ sexual health; we found that women who had been visited by an outreach worker (defined as a support worker or nurse who visits sex work venues to provide support, referral to services and sometimes STI testing) in the previous year had a 73% reduction in risk of contracting a STI, and women highly valued these services as sources of specialist, non-judgemental care. Sex worker support services work in conjunction with other local services to assist with sexual health, substance use and mental health, to support victims of violence and to support sex workers to access housing, benefits, legal and immigration advice. They may also work with sex workers and other services to avoid the criminalisation that further compounds their marginalisation and health risks. Open Doors (London, UK) is a specialist health and support service for sex workers that has operated in East London for the past 15 years. They work to promote sexual health and provide clinical services on an outreach basis in street-based sex work areas and indoor sex work venues, as well as in fixed-site clinics and informal drop-in centres. They also provide ‘case management’, which entails working with clients to identify their health and social care needs and referring them to appropriate services (e.g. primary care, housing, benefits). They have a dedicated independent sexual violence advisor to support sex workers experiencing violence and they provide wider support, helping sex workers report violence to the police through a community-based scheme, National Ugly Mugs (Manchester, UK), and advising on seeking other employment for those who wish to leave sex work.

Changes in policy context, policing practices and specialist sex worker support services

Over the past 15 years there has been a steady shift from traditional enforcement strategies against sex workers to ‘engagement and support orders. These require street sex workers to attend mandatory appointments with identified health and/or support agencies to avoid court proceedings, with the ultimate goal of ‘exiting’ women from sex work. 45 This approach is termed ‘forced welfarism’ by Scoular and O’Neill,22 who argue that this leads to ‘conditional citizenship’ whereby women who do not or cannot meet these requirements remain criminalised and constructed as ‘antisocial’. This approach has been introduced alongside increasing enforcement against men buying sex, reflecting what Scoular and Carline term a ‘creeping neo-abolitionism’ with the intention of ‘ending demand’ for paid sex. 45 Over a similar time period, sex work policy debates have become dominated by concerns about trafficking, with frequent conflation in media and political discourse of migrant sex work and trafficking. These discourses rarely consider how hostile immigration systems and broader (structural) xenophobia, racism and classism harm migrants who sell sex. 46 These arguments are further expanded in the qualitative article. 31

The impact of these policy shifts was evident in the study boroughs (Hackney, Newham and Tower Hamlets) during the course of this research. There were notable changes in policing practices and the availability of specialist sex worker support services, both of which had implications for study design and implementation. At the time of writing the proposal, long-standing advocacy by Open Doors (a key collaborator in this research), which provided services in all three study boroughs, had led to an effective cessation in police enforcement against street-based sex workers in one of the study boroughs, Hackney, between 2015 and 2017. This variation in enforcement practices across the study boroughs, as well as the presence of Open Doors, was the primary motivation for the selection of these boroughs as study sites. We envisioned that this would facilitate access to and support for participants as well as opportunities to observe different models of policing. In the context of changes in personnel, commissioning and political agendas locally, enforcement increased considerably after the project started, and Open Doors gradually had its funding removed for off-street outreach in all three boroughs and on-street outreach in two of the boroughs. Open Doors is the latest in a long line of services to face unsustainable funding cuts in London and across England in a context where sex work policies and service commissioning increasingly prioritise exiting of sex work. 22 This also took place in the context of widespread cuts to specialist services and broader social and health services across the UK, which have seriously limited integrated care and support for sex workers. 40 These changes to service provision and enforcement approaches are discussed in detail in the main findings of the qualitative study31 and also considered in routine data analyses (see below).

In this research we sought to characterise and observe the effects of this naturally occurring diversity in policing, through an innovative combination of epidemiological, social science, mathematical modelling and participatory methods, to examine how and to what extent this affected sex workers’ safety, health and service access and to predict the probable effects of removing such enforcement (see Aims and objectives). Our research design, however, was not dependent on area-level comparisons, so the changes described above did not prevent us from assessing how natural diversity in policing practices affects sex workers’ health and safety. The funding cuts experienced by Open Doors had implications for our research design and our ability to measure how the presence of a sex worker support service changes police enforcement practices over time (see Aims and objectives). However, through the qualitative study we were able to document the relationship between enforcement and changing service (de)commissioning, and the real-time impacts that such service cuts had on sex workers’ safety, health and rights.

Mixed-method approaches

We used epidemiological methods (component B) to measure the effects of naturally occurring variation in enforcement across the three study boroughs. This was used to parameterise the mathematical model (component C) by informing the development of the conceptual framework underpinning the model. Qualitative methods (component A) and collaboration with sex workers (project wide) were used to theorise the pathways through which these effects are likely to be produced, and this formed the basis for epidemiological and modelling analyses (components B and C). Consistent with an approach of ‘expansion’ or ‘grounding’ epidemiology in prior qualitative work (component A), we refined measures of the exposure (enforcement), mediator (e.g. housing, work environment) and outcome variables (component B), corroborated against routine data on enforcement (component D). Qualitative data were also used to explore how (non-)enforcement is implemented in practice, and the contextual factors that shape its acceptability and feasibility, from the perspectives of sex workers and ‘implementers’, including in areas where it has not yet been introduced. Last, iteration between the qualitative, epidemiological, modelling and routine data was used to explain and interrogate the complex social processes measured and associations observed, including through community involvement/engagement activities. The chronology and integration of the study components is summarised in Figure 1.

The mathematical model acted as a formal integrative component extending and integrating the results of the quantitative and qualitative data analyses. Evidence from the qualitative analysis was used to support assumptions about causal relationships between structural factors and rates of violence experienced by street-based sex workers from clients. We focused on client violence in the model as one example of the violence experienced by sex workers and because the causal pathways between enforcement and client violence were clearer to conceptualise in a mathematical model than the more complex and indirect pathways between enforcement and violence from intimate partners and other members of the community. Causal relationships were built into a mathematical model and parameterised to fit the data observed in the quantitative analysis. We used the model to estimate the proportion of violence attributable to each structural factor and to predict the reduction in violence that would occur if particular interventions were implemented that change the prevalence of the structural factors.

Interdisciplinary, participatory action research

This research drew on participatory action research methodologies in an interdisciplinary project. Co-applicants with expertise spanning epidemiology, sociology, mathematical modelling, criminology, participatory action research, sexual health medicine and evaluation developed the original research proposal in collaboration with Open Doors and in consultation with a number of sex workers and sex worker organisations [including the English Collective of Prostitutes (London, UK) and the then-named Sex Worker Open University, now the Sex Worker Advocacy and Resistance Movement (London, UK)], some of whom became involved in the research team and/or advisory group. Early discussions between these organisations, individuals and the co-applicants on this research highlighted ways in which police and local-authority enforcement actions and broader criminalisation endangered sex workers, eroded trust and created barriers to housing and welfare services. These discussions also informed proposed research methods and recruitment strategies. Once funding had been secured, university-based staff hired teams of freelance community co-researchers (see below) to work in partnership on study design, implementation, analysis and dissemination. We presented and sought feedback on our proposed research at the UK Network of Sex Work Projects conference Policy, Policing & Protection (Manchester, UK, March 2015), after being invited to present and join a panel discussion on the health implications of sex work criminalisation. There was strong support for the proposal and we gained valuable insight into the ways that sex workers feel that police enforcement and criminalisation currently affect their health and safety in London and across the UK.

The project was steered by an advisory group that included sex workers, activists, residents, service providers, local-authority and police representatives and academics, some of whom had provided input on the original proposal. The study advisory group met four times throughout the course of the study. They advised on the development of research instruments, sampling methods, interpretation of findings, write-up and dissemination.

Co-researchers included people with lived experience of sex work or of working closely with sex workers in sex worker-led organisations or in health and support services. They had varying prior research experience, ranging from being entirely new to research to being doctoral graduates, and combined expertise and interests in health promotion, criminology, sociology, anthropology, gender and sexuality studies, psychology, statistics, community organising, journalism and mathematical modelling. In the qualitative component, we began with collaborative learning sessions facilitated by a university-based staff member, during which we discussed qualitative and participatory methods, ethics and context; co-refined our research design, questions and tools; and conducted pilot interviews and walks [see Qualitative study (component A)]. University staff and co-researchers worked together to recruit participants, conduct interviews and walks, analyse data and disseminate findings, with regular team meetings to plan and adapt the research. Co-researchers with greater availability became more involved in analysis, writing, dissemination and decision-making, including in relation to resource allocation for remaining fieldwork and analysis [see Qualitative study (component A), Analysis]. In the quantitative component, co-researchers with expertise in sex work, service provision, epidemiology, sociology, statistics and/or criminology contributed to developing the methods, gathering and analysing the data and disseminating and writing up findings. Regular research team debriefs provided continuous feedback, including on survey burden, and various recommendations were adopted, including on payment amounts, interview locations and conduct. We consulted with local sex worker support services and sex worker advocacy groups to define appropriate methods of recruitment and ultimately assist with participant recruitment through their networks. Participatory approaches were used to develop and define the focus of the mathematical model in several ways. A presentation on modelling methods attended by university staff and co-researchers was followed by discussions to agree potential outcomes, stratification of population groups and the focus of structural indicators. Subsequent modelling meetings included co-researchers who contributed feedback on interpretation of preliminary modelling results and further analyses needed.

Following the end of qualitative and quantitative fieldwork, preliminary findings and recommendations were presented at the Fifth International Conference on Law Enforcement and Public Health (Edinburgh, UK, 21–23 October 2019)48 and at three community events in each of the study boroughs in February and early March 2020. Prior to the conference, co-researchers and university-based staff presented preliminary findings to the wider group of co-researchers and the study advisory group, incorporating their feedback on interpretation and recommendations into the conference presentations. The three community events were attended by study participants as well as other sex workers, service providers, police, local-authority representatives and third-sector organisations. These events combined presentations and group discussions led by one of the co-researchers, during which we sought feedback on the emerging findings and recommendations, with particular emphasis on hearing from participants and other sex workers. We wrote up anonymised notes from these events and used these to inform project outputs.

Through this participatory approach we have sought to challenge hierarchies of knowledge production about sex workers’ health and related epistemic exploitation, which has seen sex workers frequently excluded from related discussions and/or expected to educate non-sex-working academics and other privileged communities about their lives without adequate compensation or recognition as experts in their own lives. 49 However, it is important to acknowledge persisting power imbalances in the context of an interdisciplinary research grant held by university-based staff hiring co-researchers on a freelance basis. In a forthcoming methodological article led by one of the co-researchers on this project, we discuss the tensions, complexities and potential of this approach. 50

Additional detail on methodologies

Full details on study methods are included in the four articles published from the study. 31,51–53 In this synopsis we outline additional detail on methods not published in these articles.

Interviews

We identified other stakeholders in various ways. First, we sought the advice of collaborators, advisory group members and stakeholders interviewed to identify key agencies, sectors and individuals whose work pertained to the research question. Second, we noted key agencies repeatedly mentioned in interviews with participants. Last, if no specific individual had been recommended, or if the individual mentioned had left their post, we approached recommended organisations and individuals according to their current job titles. In the case of other adults working in the sex industry (i.e. in roles other than selling sex), we approached people we met during fieldwork and, in one case, someone recommended by a study participant. We had greater difficulty recruiting stakeholders in housing, community safety, police and some sex worker support services, but we were ultimately able to interview police, service providers and local authority representatives across all three boroughs. We suspect that the difficulty in recruiting some stakeholders is related to both the conditions of austerity affecting their workloads/capacity and the sensitivities of the research topic. We had little success in conducting formal interviews with ‘other adults’ working in the sex industry, such as receptionists, managers and security guards. We had originally planned to undertake up to 10 such interviews, depending on sampling considerations, recruitment opportunities and resources available. We sought to ensure that at least half of all interviews were with sex workers and that we interviewed a wide range of other stakeholders across diverse sectors in each borough. Of the five ‘other adults’ working in the sex industry we met during fieldwork and invited to interview, just one ultimately participated. We suspect that this may relate in part to fears over criminalisation, since current legislation criminalises all third parties working in the sex industry. Because securing additional interviews involved considerable time commitment, we decided to prioritise interviews with sex workers to ensure that their voices were centred in the research. Nevertheless, during neighbourhood walks and recruitment visits to sex work venues, we engaged in multiple informal conversations with receptionists, managers, staff and security guards in locations where participants worked and/or spent time. These provided important insights into working conditions and the broader context in which participants worked and lived.

During the interviews we asked participants about their experiences of police and other enforcement, safety and violence at and outside of work, reporting violence and other crimes to the police, access to health and social services (e.g. housing, benefits, legal and immigration advice), community and other support networks and any changes they had experienced in recent years. We also asked participants for their views on current sex work laws in England, client criminalisation in Sweden and the decriminalisation of sex work in New Zealand – models that are widely debated internationally and that have been recommended for consideration in England by the HASC. 34 For participants who did not know or were unsure about the specifics of these laws, we described them briefly and sought their perspectives on each one in turn. We asked other stakeholders about the same topics as participants, and about what they perceived to be the role of their and other institutions (e.g. police, local authorities, health services) in shaping these issues. We developed interview topic guides informed by our review of the international and UK qualitative literature on this subject6 and by our team and advisory group’s collective knowledge about sex work policing, service commissioning and provision, the sex industry and sex workers’ lived experiences locally.

At the end of each interview, we completed a demographic form with questions on the participant’s age, gender identity (at and outside of work), ethnicity, work sector and duration in work, and, for sex-working participants, yes/no questions about experiences of enforcement at work, contact with sex worker health and support services, and membership in sex worker organisations. Participants either filled these in themselves or, if they preferred, the interviewer asked them the questions that they had not already provided information about during the interview itself. For the six interviews conducted through interpretation, we hired Portuguese- and Romanian-speaking interpreters who had experience of working with sex worker support services (freelance or employed) and who were, in all but one case, known to the participant.

Walks

Of the six neighbourhood walks, three were led by people who sold sex in the study boroughs. These were similar to ‘walking interviews’ in which participants take the researcher(s) around spaces that form part of their everyday lives and engage in discussion about their lived experiences of these spaces, offering opportunities for more participant-led data collection. 56 We invited participants to map out the spaces in which they worked and spent time, with particular reference to where they encountered and/or avoided police, other authorities and services, where they experienced threats to their safety and well-being and where they did and did not feel comfortable. We then invited them to walk us (1 or 2 researchers, in one case accompanied by an interpreter) around spaces that they felt were safe and appropriate for us to visit together. We audio-recorded the mapping and walks, with participant consent, ensuring that we recorded when only their and our voices were audible. Two of these walks were led by cis women through street sex work areas in which they worked and lived. The third was led by a cis male sex worker who took the researcher to an area where he met clients, socialised and used to live, including outdoor spaces, virtual spaces (apps) and bars. The three remaining walks took place in street sex work areas, led by one of the co-researchers with lived experience of street sex work and included 1 to 2 other members of the research team. During these walks we walked and drove around main streets, told sex workers about the research, offered condoms and information on sex worker-friendly health, support and rights services, engaged in informal conversations with sex workers and other individuals present in street and other settings (e.g. fast-food restaurants where participants spent time) and observed these spaces. These walks offered us more in-depth insight into the spaces in which participants worked, lived and experienced enforcement. Afterwards, we wrote fieldnotes to help contextualise the audio-recorded walk data and the spaces that participants described in fixed-site interviews.

Informed consent

All participants in interviews and walks provided informed consent, written or in the presence of a witness independent of the research team, and were assured of the confidential and anonymous nature of the study. We started by giving participants £20 or £40 in thanks for participation in a fixed-site interview or longer mapping/walking interview, respectively. We later increased the former to £40 on the advice of co-researchers to compensate participants more adequately for the time they contributed to the research (walking interviews had already been completed by this time). We offered participants and other sex workers information on relevant sex worker health, support and rights agencies, contacting organisations on a participant’s behalf if they wished. After each interview, the interviewer debriefed with the lead researcher to check in on their and the participant’s safety and well-being, provide any necessary support/referrals, discuss any ethics or methodological concerns and summarise the main themes of the interview. For fieldwork outside services, researchers worked in pairs and we operated an ‘on-call’ system, whereby another member of the research team, and in the case of night fieldwork university security staff, were aware of the researchers’ whereabouts and expected finish time and checked in with them by telephone regularly. Given the sensitivities around police contact in the context of this project, we agreed that the on-call researcher would call the police only as a last resort (i.e. in the exceptional circumstance of being unable to make contact with either researcher, having exhausted all means of communication). This was not necessary at any point during the research.

The qualitative study received approval from the London School of Hygiene & Tropical Medicine (LSHTM) ethics committee (ref: 13919) and the London Stanmore research ethics committee (ref: 204494).

Qualitative study

We report on the main findings of the qualitative study in the published article,31 where we analyse how participants’ encounters with police, local authorities, immigration and health and social care services affected their safety, health and broader social justice. We examine these encounters as assemblages of diverse agencies variously operating in conjunction and in tension in the context of austerity politics, laws criminalising prostitution, drugs and immigration, broader structural discrimination and gentrification. Here we provide an overview of how participants described their experiences of enforcement and summarise the key themes presented in the qualitative study article. 31

Participants described highly varied enforcement targeting sex workers, clients and workplaces. Cis and trans women who met clients outdoors reported the most frequent, intense and violent policing. They described being pursued by police and local authorities and photographed by officers or van-mounted cameras without warning or consent. They described having condoms and drug use equipment confiscated, being banned from areas in which they worked and lived through prostitution- and/or ASB-related enforcement measures and being fined, arrested and detained for breaching related warnings:

Mostly they stop us with the camera . . . It’s a big van with a camera on top. They come in the van and they focus the camera on us so, of course, they stop us. They take our details, everything. After that they call the court and they send a bigger van to arrest us. [Interviewer: Is that a police van or is it the council?] That’s what we believe. We could never make out what’s written on it.

Woman, works primarily outdoors

I can be stopped walking down the road four times in a day, name checked . . . If I walk from here to the shop they stop me . . . They don’t play by the rules . . . I’m a known working girl . . . [When I wasn’t working] they turned round and said to my mum’s neighbour, ‘You do know she’s a prostitute, yeah?’

Woman, works outdoors

Some participants described being stopped and/or arrested when caught with clients, sometimes with no action taken against the client, and in other cases clients being arrested and women being subject to court diversion schemes. 31 The few migrant participants working outdoors had not encountered immigration authorities while sex working. However, close connections with the criminal justice system meant that police enforcement could ultimately result in immigration detention, including for those with European Union (EU) citizenship, as happened to two participants:

[Two days before] my release date [from prison] . . . they came with a ‘liable for deportation’ order . . . I’ve lived here all my life . . . I’ve got a child here, I’ve got my family here . . . I’ve been in care under [name of London borough].

Woman, works outdoors

Fewer participants working indoors had experienced enforcement at work. This aligns with research demonstrating the disproportionate burden of enforcement on street sex workers. 6 However, we suspect that this also relates to difficulties recruiting participants following raids on indoor sex work premises, because of the disruptive effects of such raids. Before we were able to interview several women who we had met through outreach services, we lost contact with them after a series of police raids led to their working and living premises being closed down – a pattern also described by stakeholders supporting women who had been mis-charged with brothel-keeping and/or deported. A number of cis and trans women described intimidating ‘visits’ and raids by police and immigration officers where they worked and/or lived, typically under ostensible antitrafficking interventions and drug searches. Participants described these visits as closely resembling their and others’ experiences of armed robbery, particularly when officers posed as clients:

[Immigration authorities] made an appointment with me as a client . . . I saw one person, but when I opened the door, I saw that bunch of people . . . That scared me . . . You even think . . . it’s a gang, right? . . . I showed them my passport . . . They searched upstairs . . . I told them that I work alone.

Woman, works indoors alone

Women also described having funds and belongings confiscated and colleagues having been detained and deported.

Cis men and non-binary participants had not experienced enforcement while working. Yet, as for cis and trans women, the potential for this within a criminalised framework still influenced how they worked and sought justice, particularly for those who had insecure immigration status and/or used drugs at work:

There’ve been other incidences where drugs have been involved and, you know, consent has been broken or . . . quite grey . . . I wouldn’t call the police, but I think often it’s implicit that a sex worker would never call the police. That’s generally the feeling. You wouldn’t speak about it because it’s understood that the police wouldn’t be a first resort, they wouldn’t be a last resort . . . especially if drugs were additionally involved. [. . .] There are points at which . . . in theory I could have approached the police about crimes that had been committed against me but I didn’t, and wouldn’t have . . . just because I absolutely don’t trust the police as a whole . . . and also because this happened . . . when my immigration status was being assessed. Whether or not that would have had an affect I don’t know . . . I didn’t have the most secure sort of status . . . even if nothing would have happened . . . I didn’t want to risk it.

Man, works indoors, used to work outdoors

Enforcement restricted how safely participants could work, their income and their well-being. Funds lost through fines and confiscation meant longer working hours. Avoiding on-street local-authority and police enforcement – targeting either themselves or their clients – made it harder for women to generate income and work safely. Denisa described forgoing her own safety to avoid police detection: ‘When I’m behind the fence the police don’t see me but [. . .] someone can approach me from behind and I can’t see him’. Women sometimes expressed gratitude when police permitted their clients to pay them before arresting the client, relative to enforcement without payment. However, some feared recriminations from clients assuming they had ‘set them up’, and women were still generally issued mandatory appointments with designated services three times in 6 months to avoid court proceedings. Migrant women described policing of indoor premises that jeopardised work and housing and left them reliant on exploitative workplaces. After police came to the flat where she was working, Anna told us that, ‘going home[,] I was scared [. . .] I can’t sleep all night [so] I try again [to] work in [former venue tolerated by police where manager is violent]’. Participants without UK residency expressed ongoing fear of being deported and recalled others’ deportations. The few migrants working outdoors had not encountered immigration authorities while sex working, but police enforcement could culminate in immigration detention, including for EU citizens, as happened to two participants. Prison and immigration detention uprooted participants’ lives and threatened income and physical and mental health. Participants detained by immigration authorities were unable to bring possessions and money to detention facilities and received no funds on release. One participant described the stress of accepting a client’s request for sex without a condom in these circumstances, which she would otherwise have refused.

In the analysis reported in the qualitative study article,31 we drew on interview and neighbourhood walk data with sex workers and other stakeholders to develop three key themes relating to (1) binary notions of ‘community’ and ‘vulnerability’ underpinning (structurally) violent policing and injustice, (2) disciplining in and of health and social services through service conditions and cuts and (3) alternative visions of social justice grounded in lived expertise. These are summarised in Figure 2 and explained here.

FIGURE 2.

Summary and explanation of key themes derived from qualitative analysis.

Cohort study

A total of 288 individuals completed baseline surveys (original baseline, n = 252; expanded baseline, n = 36). Among the sample, 91 individuals (26.5%) identified as male, of whom < 10 identified as trans men, and 197 (68%) as women or non-binary, of whom < 10 identified as trans women or non-binary. Seventy two participants (26.4%) identified as ethnically or racially minoritised, including Asian or Asian British (4.4%), Black, African, Caribbean or Black British (9.1%), mixed or multiple ethnicities (8.0%), or otherwise ethnically or racially minoritised (4.7%) including Traveller or Roma (< 10) and Middle Eastern (< 5). Overall, 123 individuals were followed up (retention 55.4%). In total 36% found clients from street settings and 64% found clients in off-street settings, including 40% working independently and advertising online, 8% working at a managed premise (e.g. massage parlour/sauna or flat) and 10% working only with regular customers. Less than one-third (28.4%) were non-UK nationals. The median age was 31 years (IQR 25–39 years) and the median duration in sex work was 6 years (IQR 3–14 years).

Key findings from the cohort study are published elsewhere,51 where the primary analysis (objective 3) focused on cis and trans women who sell sex is presented. We also presented findings at the Fifth International Conference on Law Enforcement and Public Health. 67 In these analyses we stratified findings by working sector, comparing the experiences of cis/trans women who find clients in street-based settings to those finding clients in off-street settings (defined as flats, saunas, hotels and online). There were too few trans and non-binary participants to examine their experiences separately. For non-binary participants, we examined the gender identity they worked under (which was in all cases female or male).

We show that cis and trans women who worked on the street (n = 90) experience extreme levels of social exclusion. Almost two-thirds (65%) were currently homeless and over half (52%) had previously been evicted. Among those with children, 35% had had their children taken into care; all of these participants used drugs. Over two-thirds reported difficulties in paying expenses (69%) and 52% were in arrears. All these measures were lower among women working in off-street settings: 7% were currently homeless, 14% had previously been evicted and < 10 participants had had children taken into care. Financial difficulties, however, remained widely reported among cis and trans women working in off-street settings, with 27% reporting being in arrears and 53% having difficulty paying expenses. A third (33.3%) of participants had visited a sex worker support service in the past 6 months and 73.0% were registered with a GP. Just over a third (34.6%) had an unmet mental health need, meaning that they wanted mental health care but had not received it. Women who worked on the street were less likely to be registered with a GP and more likely to have an unmet mental health need. The overall prevalence of chlamydia and gonorrhoea among those tested was 11.3% and 10.4%, respectively. Chlamydia rates were higher among those working in off-street settings but gonorrhoea rates were higher among those working on the street.

The majority of our sample of cis and trans men (n = 76) reported finding clients in off-street settings; only 10 reported working on the street. Cis and trans men reported comparable or lower levels of social exclusion, enforcement, depression or anxiety and violence from clients, intimate partners and others than do women working in off-street settings. However, the small sample size limits the generalisability of these findings.

Findings support data from other studies and are in line with the qualitative study that shows that sex workers working on the street experience higher levels of violence. In our survey, sex workers working on the street were more vulnerable to violence (from any perpetrator) than those working in off-street settings in relation to emotional violence (89% vs. 64%, respectively), physical violence (72% vs. 13%, respectively), sexual violence (72% vs. 34%, respectively) and any violence (94% vs. 68%, respectively). This same pattern applies when measures of violence are broken down by perpetrator. In addition, sex workers working on the street had a higher prevalence of anxiety or depression (71% vs. 35%, respectively) and experienced more police enforcement in the form of recent arrest (48% vs. < 5%, respectively), arrest of clients (32% vs. < 5, respectively) and history of imprisonment (69% vs. 5%, respectively) than those working in off-street settings. Among street-based sex workers, 87% had experienced any law enforcement in the last 6 months (including displacement from workplace, arrest for any reason, being cautioned, receiving a warning or confiscation of condoms, money, drugs or drug equipment). This compares to just 33% of women reporting their clients having been stopped, searched, arrested or detained in the same time frame, highlighting that the majority of enforcement is directed towards sex workers. It is particularly concerning that, as we show, police are key perpetrators of violence, with 42% of cis and trans women working on the street and 7% of those working in off-street settings experiencing violence by officers in the last 6 months. This was mostly in the form of verbal abuse and intimidation, damage to property, physical violence or sexual assault including rape or sex in exchange for no arrest. Key characteristics of all study participants at baseline are presented in Table 1.

We show that among street-based sex workers, experience of physical violence from clients in the last 6 months (54%) is comparable to levels of physical violence from other members of the community (56%). This same pattern applies to emotional violence (64% from clients, 74% from others) and rape (28% from clients, 22% from others). 67 This highlights the importance of addressing underlying drivers of violence and inequalities experienced by sex workers and cis and trans women in general. Findings also show that violence, depression and anxiety among sex workers is clearly linked to precarity in the form of homelessness, unmet access to justice, eviction and financial difficulties, and this is compounded by police enforcement practices and criminalisation, particularly for those working on the street. For example, among street-based sex workers we found that recent arrest was associated with violence from others [adjusted odds ratio (aOR) 2.77, 95% CI 1.11 to 6.94] and displacement by police was associated with client violence (AOR 4.35, 95% CI 1.36 to 13.9). Financial difficulties were also associated with client violence (AOR 4.66, 95% CI 1.64 to 13.24). Disability (AOR 3.85, 95% CI 1.49 to 9.95) and client violence (AOR 2.55, 95% CI 1.10 to 5.91) were associated with anxiety/depression. For sex workers working in off-street settings, the following factors were associated with recent physical or sexual violence from clients: financial difficulties (AOR 3.66, 95% CI 1.64 to 8.18), migration status (AOR 3.19, 95% CI1.36 to 7.49), intimate partner violence (AOR 3.77, 95% CI 1.30 to 11.0) and alcohol/drug use (AOR 3.16, 95% CI 1.25 to 7.92). Physical disability (AOR 5.83, 95% CI 2.34 to 14.51), unmet mental health needs (AOR 3.08, 95% CI 1.15 to 8.23) and past eviction (AOR 3.99, 95% CI 1.23 to 17.93) were associated with anxiety or depression. These findings are summarised in Tables 2 and 3.

Mathematical modelling

We found that, over 5 years, ending police displacement of sex workers working on the street would lead to a 35% [95% credible interval (CrI) 17% to 67%] reduction in violence. If homelessness is ended, the reduction in violence is 24% (95% CrI 9% to 37%), and if both police displacement and homelessness are ended the reduction in violence is 56% (95% CrI 44% to 65%) (Figure 3). 53

FIGURE 3.

Population attributable fraction (PAF) of violence attributable to each variable over 5 years after turning off homelessness, police displacement or both within the mathematical model. The box and whiskers plots are standard Tukey-style box plots showing the median (horizontal line); the top and bottom of each box show the first and third quantiles of the data, the whiskers extend to the largest or smallest value within 1.5 times the IQR that lies above the 75th or below the 25th percentile and the dots show all outlier points outside these ranges.

Overall, the proportion of attributable violence (i.e. of violence attributable to each factor) was higher for police displacement than for homelessness, and removing both together was slightly less than the sum of removing each individually. Changes in the rate of housing and policing also affected the prevalence of violence in the population. The impact was non-linear, with an initially gradual decline in violence with reduction in policing or homelessness and a steeper decline when policing or homelessness parameters were reduced by > 50%. For example, although removing police displacement entirely led to a 38% (95% CrI 20% to 81%) reduction from baseline, reducing displacement by 39% reduced violence by only 3% (95% CrI 2% to 6%) from baseline. Increasing the rate at which those with unstable housing are housed to match the success of a ‘Housing First’ intervention led to a 5% (95% CrI 2% to 11%) reduction in violence. 71 When both interventions were combined (i.e. reduced but not ceased police displacement, plus housing rate equivalent to ‘Housing First’), the impact increased with a synergistic effect to a 10% (95% CrI 6% to 18%) reduction in violence. These are summarised in Table 4.

Routine data

In summary, the analyses of the routine data suggested that stop and search (SAS) related to drug offences has steadily increased over the past 5 years in local areas where street sex work is conducted (Figure 4). There was no change in the use of enforcement against activities categorised as ASB (see Figure 4) or drug offences (Figure 5) across the three boroughs during the study. However, we saw a sharp increase in both of these measures during the first COVID-19 pandemic lockdown period (February–July 2020). For drug-related offences, this increase is not seen when beat areas are examined specifically, whereas for ASB a greater increase was seen in beat areas than borough wide. The routine data suggest that enforcement against sex workers remains high and there is some evidence that it has increased, particularly in the context of COVID-19 lockdown measures.

FIGURE 4.

Enforcement through the use of anti-social behaviour (ASB) measures (all genders) in (a) beat (street sex work) areas only and (b) overall in Hackney, Newham and Tower Hamlets.

FIGURE 5.

Enforcement for drug offences (all genders) in (a) beat areas only and (b) overall in Hackney, Newham, and Tower Hamlets.

Stop and search related to drug offences

SAS related to controlled drugs increased from 0.63 stops per month between 2016 and 2017 to 4.5 per month from February 2018 to 2020. This was against women and is limited to SAS for suspected drug-related activities, which is closely aligned with the type of enforcement that female sex workers who work on the street experience. The breakpoint analysis fitted a slope of 0.75 events per month up to June 2018, which increased to 4.6 events per month for the remainder of the data period. If the rate of increase in SAS had remained stable in 2018, the total number of SAS would have been 39% lower at the mid-point of the cohort study. Figure 6 summarises enforcement related to SAS against women in all three boroughs.

FIGURE 6.

Stop and search against women related to controlled drugs in Hackney, Newham and Tower Hamlets. The solid line shows the breakpoint analysis linear regression; the dashed line shows the forward projection of the line prior to the breakpoint; horizontal dotted lines represent the start and end dates of the East London Project cohort data collection. Orange dots are two outlier points that were excluded from the breakpoint regression.

Implications and recommendations

Our research has clear implications for policy and practice, which we summarise here.