The Covid-19 Pandemic Endangers Sex Worker Health and Safety, Underscoring Need for Structural Reforms

In the United States and around the world, the Covid-19 pandemic continues to reshape our understandings and experiences of work. Since the pandemic’s start in early 2020, millions of people in the United States lost their jobs, millions more adapted to home working arrangements, and our societies continue to grapple with difficult questions about the treatment and compensation of essential workers.1“The Plight of Essential Workers during the Covid-19 Pandemic,” editorial, The Lancet 395, no. 10237 (2020).

While the pandemic has affected work and life for all of us, reports from sex workers, sex work organizations, and journalists in the United States and around the world suggest that the pandemic has impacted sex workers in unique and profound ways. Further, public health experts, including sex workers, warned early in the pandemic that the health needs of sex workers were being sidelined2Sally Howard, “Covid-19: Health Needs of Sex Workers Are Being Sidelined, Warn Agencies,” BMJ 369 (May 7, 2020). and advocated for sex work inclusive Covid-19 research, support initiatives, and policies.3Lucy Platt et al., “Sex Workers Must not be Forgotten in the Covid-19 Response,” The Lancet 396, no. 10243 (2020): 9–11.

In 2020, a new program of research known as Sex Work & Covid-19—or SW-C19—was established to collect evidence of the pandemic’s impact on sex workers. This collaborative enterprise involved researchers, sex workers, activists, advocates, and some who represented all of these categories. More than simply describing how the pandemic has affected sex workers, we wanted to understand why things have played out as they have and, importantly, what support sex workers identify as critically needed now and in the future.

How has the Covid-19 pandemic affected sex workers?

In August last year, we sat down with Sam, a multiracial nonbinary sex worker based in New York City, to conduct an in-depth research interview via videoconference. This interview was one of 21 separate interviews carried out last year, which we hoped would provide one kind of empirical foundation upon which to build a better understanding of the Covid-19 pandemic and sex work.

“It has pretty much obliterated my work,” Sam described. “My dungeon was shut down back in March, so the physical space where I usually do my sex work is shut down because of Covid.”

After conducting dozens of interviews, Sam’s story was all too familiar. As understandings of SARS-CoV-2 transmission developed and public health orders to control its spread were implemented, in-person sex work became a difficult and potentially dangerous gig. Sex work venues were ordered closed, client interest decreased, and sex workers worried about acquiring or transmitting the virus.

Aligning with what was shared during the interviews, through a separate analysis of one of the world’s largest sex work websites, we found that many sex workers discontinued in-person work in the pandemic’s first four months.4Denton Callander et al., “Investigating the Effects of Covid-19 on Global Male Sex Work Populations: A Longitudinal Study of Digital Data,” Sexually Transmitted Infections 97 (Feb. 17, 2021): 93–98. While discontinuing in-person work can reduce Covid-19 risk, it also denies sex workers an important source of income. Some of the people we interviewed used sex work to supplement pay from other jobs, but for many it was their primary or sole source of income. Many of these people could simply not afford to just stop work.

Unfortunately, income loss and other effects of the pandemic can force sex workers to make an impossible choice between their health and meeting basic needs. “If I have to eat or I don’t have any lodging or any means of taking care of myself,” explained Rochelle, a Black transgender female sex worker and health promotions officer, “that might be a chance I’m willing to take, even though it jeopardizes my safety.”

Looking across interviews, we identified prominent threats to the health and safety of sex workers as a result of the Covid-19 pandemic. By no means exhaustive, these include:

• Covid-19 infection risk owing to intimate sexual contact;
• food insecurity, housing instability, and houselessness owing to lost income;
• decreased access to physical and mental health services owing to reduced services and fears of mistreatment;
• increased mental health challenges owing to social isolation and reduced service access;
• increased risks of violence from seeing clients in unvetted spaces (e.g., motels) owing to financial need, housing instability, and sex work venue closure; and
• increased health risks from engaging in sexual practices that would otherwise be refused (e.g., condomless sex) owing to financial need.

The pandemic’s impact on the general population is best understood from an intersectional perspective,5Lisa Bowleg, “We’re Not All in This Together: On Covid-19, Intersectionality, and Structural Inequality,” American Journal of Public Health 110, no. 7 (2020): 917. and this is true for sex workers as well.6Nicole F. Bromfield, Meg Panichelli, and Moshoula Capous-Desyllas, “At the Intersection of Covid-19 and Sex Work in the United States: A Call for Social Work Action,” Affilia 36, no. 2 (2021): 140–148. Indeed, we observed that the effects listed here were most pronounced among sex workers of color, transgender and migrant sex workers, and those of lower socioeconomic status.

Why has the Covid-19 pandemic endangered sex workers?

While sex workers have been negatively affected by the pandemic, those in other employment sectors (especially leisure, tourism, and entertainment) have also faced their share of challenges. On the surface this comparison may seem reasonable, but it ignores an incredibly important distinction: Sex work is highly stigmatized.

Stigma enacted against sex workers is a pervasive social force that predates Covid-19 by millennia and can be applied to explain why individuals and societies treat sex workers differently from, for example, restaurant servers, taxi drivers, or social scientists. In simple terms, because sex work is commonly perceived and portrayed in our societies as immoral, deviant, and dangerous it marks those associated with it as worthy of derision, fear, or pity, all of which drives and is driven by laws and regulations of sex work.

In the context of Covid-19, stigma offers a compelling explanation for the pandemic’s unique and disproportionate effects on sex workers. While stigma impacts all sex workers, we found that things are much worse when sex work stigma intersects with racism, sexism, transphobia, classism, and other forms of oppression.

Criminalization of sex work in nearly all parts of the United States represents a structural form of stigma that impacts sex workers relative to the pandemic in several ways. First, criminalization prevented the majority we interviewed from accessing government-sponsored financial aid. Further, early reports of sex workers’ explicit exclusion from some aid programs discouraged applications to others. Compounding the pandemic’s financial effects, those of lower socioeconomic status were hardest hit and experienced cascading threats to their basic needs like food and housing.

Second, criminalization also acts as a barrier to providing sex workers with health insurance.7Michael L. Rekart, “Sex-Work Harm Reduction,” The Lancet 366, no. 9503 (2006): 2123–2134. While not pandemic-specific, uninsured sex workers we interviewed reported stress and anxiety from fears of being diagnosed with Covid-19 and the resulting out-of-pocket medical expenses. This concern resonated with migrant sex workers especially. Third, some of the peer-support workers and sex worker activists with whom we spoke advised that criminalization impeded programs to negotiate housing for sex workers during the pandemic, especially for those who are transgender.

The fourth effect of criminalization was articulated by Cathy, a Native American cisgender female sex worker based two hours west of Boston. “When Covid first started, there was nobody outside,” explained Cathy, “so I guess it made it look even more suspicious with people driving around and then the girls walking around.” Sex workers of color or lower socioeconomic status are overrepresented among those who operate in public places like street corners and parks. They are also more visible than other kinds of sex workers—and made hypervisible during the pandemic—and this visibility can expose them to disproportionate policing and diminishing safety.

Identifying all sex work as trafficking is another form of stigma that negatively affects access to mental and physical health care. Specifically, some sex workers we interviewed were afraid of attending health services lest they be flagged for involvement in human trafficking, a particular fear among migrant sex workers. Among others, fears of being treated differently by service providers because of their sex work also impeded service access, further demonstrating stigma’s pervasive influence.

What can be done to support sex workers in the Covid-19 pandemic?

With mounting evidence from our team and others, now is the time for researchers, policymakers, funders, and activists to work together toward meaningful change.

To that end, our research lends support to a number of structural reforms that could assist sex workers in this new Covid-19 era. Centering the needs of sex workers themselves, we recommend the following:

1. Decriminalize sex work. Many of the pandemic’s effects unique to sex work are fostered by its criminalized nature. Decriminalizing sex work would not only address many barriers that exacerbate the pandemic’s harms but also stands to improve health and well-being in many other domains. As decriminalization gains traction in some parts of the United States, rigorous and community-centered social research can help advance this important work, including by highlighting the pandemic-specific effects and implications.
2. Support sex work organizations. We find that the pandemic’s worst effects are often ameliorated by social support from sex work communities. Continuing a tradition of public health engagement,8Rekart, “Sex-Work Harm Reduction.” sex work organizations have responded to the pandemic with “safer sex work” guidelines,9Denton Callander et al., “Sex Workers Are Returning to Work and Require Enhanced Support in the Face of Covid-19: Results from a Longitudinal Analysis of Online Sex Work Activity and a Content Analysis of Safer Sex Work Guidelines,” Sexual Health 17, no. 4 (2021): 384–386. financial aid programs, housing and food initiatives, education and support forums, distribution of risk reduction equipment, and other important programs. Dedicated public funding would help expand this work in the United States, which researchers can support through data-driven advocacy and rigorous evaluations of impact.
3. Redevelop anti-trafficking initiatives. Human trafficking is an important issue, but current training for health and support services problematically ignores the nuances of consensual sex work while enforcement initiatives largely capture sex workers and not traffickers. Redeveloping these initiatives with recognition of consensual sex work and centering sex workers as partners in the fight against trafficking would address barriers to care illuminated by the pandemic, support the destigmatization of sex work among service providers, and could even help advance anti-trafficking work.10Erin Albright and Kate D’Adamo, “Decreasing Human Trafficking through Sex Work Decriminalization,” AMA Journal of Ethics 19, no. 1 (2017): 122–126.

Supporting sex workers long-term

While vaccines offer a hopeful future end to the Covid-19 pandemic, sex workers continue to be affected in ways that cannot be resolved with a shot in the arm. Indeed, many of the pandemic’s most pressing effects on sex workers—especially socioeconomically and in terms of mental health—are likely to endure well into the future.

Relative to individually focused interventions and initiatives, structural reforms are typically much more difficult to achieve. This truth notwithstanding, they are also often the most impactful. In focusing on structural reform, we wish to recognize the long-term implications of the pandemic. Further, focusing on structural change acknowledges that if not addressed, the same conditions that have made the pandemic so harmful to sex workers will continue to plague their health and safety.

Stigma remains a persistent threat to the health and safety of sex workers, the significance of which is reignited by Covid-19. As stigma intersects with other forms of oppression, sex workers who are particularly vulnerable to social marginalization are also the most at risk. Destigmatizing sex work within a framework of intersectionality is a daunting and seemingly endless journey, but it is essential that we carry on by centering diverse sex work communities and working together to address the individual and structural challenges illuminated by but certainly not unique to Covid-19.

Banner photo: Juno Mac/Flickr.