People who engage in sex work present with unique vulnerabilities for numerous health issues. In addition to being at increased risk of experiencing sexually transmitted infections and blood borne viruses such as HIV/AIDS or hepatitis [1738–1741], sex workers are at increased risk of experiencing both AOD and mental health conditions [1742]. Previous international studies from the UK and US have estimated that among people who use AOD, a history of sex work ranges between 31 – 51% of women and 8 – 19% of men, with an estimated 41% of women and 11% of men engaging in sex work in the past year [1739, 1743]. Internationally, these rates appear to be higher among people attending AOD treatment than people who use AOD in the general population [1739, 1743]. Compared to Australians who inject drugs who have never engaged in sex work, sex workers in Australia who inject drugs also are more likely to start using AOD at a younger age, and have more AOD-related problems [1744].
There is also evidence of poor mental health among sex workers, including high rates of depression, psychosis, anxiety, suicide attempts, and mental health treatment [1739, 1745]. However, estimates vary based on whether a person is engaged in sex work that is considered legal as opposed to illegal sex work. Compared to licensed brothel workers and private operators, people who engage in illegal sex work are four times more likely to present with mental health problems in Australia, and these increased rates of mental health problems are associated with more adverse experiences prior to entering the industry [1746]. Trauma exposure is almost universal among Australian sex workers (99%) [1747] with estimates of violence against sex workers ranging between 45-75% [1748]. A higher incidence of violence has also been found among street-based sex workers compared with other types of sex workers (e.g., indoor) [1749, 1750].
Australia’s approach to regulating sex work is complex, involving legalisation, criminalisation, and decriminalisation of particular aspects of sex work, which varies between Australian jurisdictions. A full review of regulatory approaches is beyond the scope of these Guidelines; however, AOD workers should be aware that Australia’s policy approach has significant implications for those working in the sex work industry. For example, at the time of writing, the operation of licensed brothels and registered sex workers in Victoria are decriminalised, while other unlicensed activities remain criminalised [1751]. In contrast, Tasmania has criminalised brothels, but private sex work (excluding street-based) is legal. The legal status of a person’s workplace has implications for their health and safety (e.g., reasonable shift length, breaks, use of safety equipment such as condoms), and may also impact on the likelihood of the person seeking help. Both Australian and international research demonstrates that people who engage in sex work in legalised or decriminalised environments report greater awareness of health conditions and health risk behaviours, and engage in safer sexual practices (e.g., increased condom use), in comparison with those working in criminalised environments [1738, 1752]. As such, decriminalising sex work may help to improve the safety and representation of sex workers, though Treloar and colleagues [1753] argue that decriminalisation is not sufficient to reduce the pervasive stigma associated with sex work, which may also prevent a person accessing health services.
Several key barriers to accessing healthcare have been described, with 70% of sex workers in one study identifying one or more institutional barriers to accessing health services [1754], including stigma, discrimination, social exclusion, violence, and criminalisation of sex work [1755]. Sex workers may fear judgement from service providers, feel uncomfortable about disclosing the details of their employment, or fear the consequences of disclosing any illegal sex work. The fear of disclosing the nature of their work may also extend to families and/or friends, with the constant vigilance needed to maintain multiple identities contributing to isolation and fatigue [1753].
A study of healthcare professionals in the UK concluded that the main barriers to providing healthcare to people who engage in sex work are institutional, such as services being inflexible, under-resourced, and not trauma-informed [1756]. These barriers may explain the low rates of sex workers accessing mental health treatment. In an Australian study, only 14% of people who engaged in sex work reported accessing counselling services and 11% reported accessing mental healthcare [1742].
There is little research to guide treatment approaches for working with people who engage in sex work specifically, but given the aforementioned issues, AOD workers should be guided by the guiding principles for working with people with co-occurring conditions (see Chapter A3), trauma-informed care (see Chapter B2), assessing risk (see Chapter B4), and coordinating care (see Chapter B5).