Sex work, or prostitution, is the provision of sexual services for money or its equivalent. Sex workers may be male, female, or transgendered, and the boundaries of sex work are vague, ranging from erotic displays without physical contact with the client, through to high risk unprotected sexual intercourse with numerous clients. Individuals may occasionally and opportunistically exact a fee or gift for a sexual favour without perceiving themselves to be sex workers, or they may engage more or less full time in the explicitly commercial provision of sex services. This variability results in a spectrum of implications for public health and health service provision; yet sex work is typically stigmatised and often criminalised.

Particularly in developing countries, interventions with sex workers—health education, screening, and treatment for sexually transmitted infections, and condom supply—are the most cost effective HIV control strategy.¹ Developing appropriate interventions requires a comprehensive picture of the shape and location of local sex industries.² To aid programme managers in this task, we sought to develop a typology of sex work that can be used as a checklist for situation assessments.

METHODS

A Medline search and review of 681 “prostitution” articles published in English from 1996–2004 was conducted. In addition, the investigators pooled their 20 years of collected papers and monographs on sex work, as well as observations in more than 15 countries, particularly in the Asia-Pacific region and Latin America. These included direct field notes, conference presentations, government and non-government inquiries, national HIV programme assessments, and advice from key local informants.

The broad grouping of “direct” and “indirect” sex workers was used because it is already in general usage, particularly in Asia. The narrower categories were arbitrarily based on worksite, mode of soliciting clients, or type of sexual services provided. The broad categories of “high class” and “low class,” reflecting the sex worker’s income, was considered but not used in the main typology because income is a continuum and different “classes” of sex worker can be found in any one type of sex work. Our initial aim was to illustrate the variety of social contexts in which prostitution occurs.

RESULTS

Types and social contexts of sex work

Only in the most extreme social situations, such as the Cultural Revolution in 1960s China³ and the Taliban regime in Afghanistan, has commercial sex probably been quantitatively suppressed. Typically social and legal sanctions against sex workers merely succeed in displacing the activity into other localities^4,5 or into a different kind of working arrangement.^6,7 Every country, and every region within those countries, has a different composition to its sex industry—shaped by history, social and economic factors, legal framework, and policing practices.

The reasons why people take money or gifts for sex are very varied. In some ancient traditions prostitution was recognised as the hereditary calling of particular subgroups or castes. In these cases women were “born into prostitution.” There are echoes of this practice in India and Nepal where descendents of temple dancers (Devadasis) and female court musicians (Nautch girls) still follow their “hereditary” calling, although their ritual significance is greatly diminished.^8,9

Currently most sex work has a strong economic basis, primarily as a source of income for sex workers, but also for dependent kin and associates including pimps, managers, and ancillary workers.¹⁰ Individual sex workers have very different levels of need ranging from survival,¹¹ debt,¹² drug dependency,¹³ coercion,¹⁴ and social connection,¹⁵ to desire for wealth and social mobility.^15,16 These underlying motives affect the sex worker’s autonomy and ability to respond to health promotion messages.¹⁷ For example, a refugee with dependent children in a war zone is less empowered to insist that a passing soldier uses a condom than an escort in a wealthy country, who may be supplementing her income to buy a better car.

Direct prostitution

Table 1 lists a variety of sexual services widely recognised as “prostitution” because it is clear that the primary purpose of the interaction is to exchange sex for a fee. These services are referred to as “direct” prostitution, though there is great variety in the social context and possible harms associated with these transactions.

Street or other public place sex work is probably the most widespread type of prostitution globally. Large numbers of street based sex workers can be an indicator of socioeconomic breakdown¹⁰ in developing and war torn countries.¹¹ In wealthy countries sex workers are more likely to solicit publicly if legislation denies them access to indoor venues, they are drug dependent, or there is an employment crisis.²⁹

Many sex workers regard street work as undesirable because of the danger of violence and other forms of social hostility.¹⁸ Nevertheless some prefer the relative autonomy and unregulated conditions of outdoor work.¹⁸ In a minority of settings street work is more lucrative and therefore more prized by sex workers.^16,30 Sometimes the lack of privacy limits services to providing oral sex or “hand relief,” thus reducing associated health risks.³¹

Instead of waiting for passing trade, some sex workers actively seek their clients in male dominated venues such as pubs, clubs, hostels or hotels.²⁵ Others frequent transport hubs, servicing travellers and crew for cash or intercity travel.^10,26 In an extension of street work, some sex workers in the United States drive their own cars on interstate highways soliciting truck drivers via CB radio.²⁷

Between soliciting in public and indoor sex work are doorway and window prostitution. The red light areas of Hamburg and Amsterdam are well known for their “shop” window sex workers.²³ More commonly sex workers in poorer European suburbs, and many parts of the developing world, solicit passing trade from the doorways of small brothels or their own homes.²⁴

Indoor sex work is typified by brothel prostitution. Brothels vary enormously in their size and décor from mere hovels through tenement bedrooms to elaborate “pleasure palaces” with lavish fantasy themes. Brothels also vary in their administration from individual “houses” to fully staffed business enterprises. The human rights and working conditions of brothel prostitutes are similarly varied, but brothels generally offer greater security than the street in terms of personal safety and the ability to provide some health care and education. Brothel prostitution is found in most places where there is a significant sex industry and it is the form most likely to be the subject of state regulation.

Another widespread form of indoor prostitution is escort prostitution where sex workers are contacted by phone and travel to the clients’ premises. Escort agencies may operate internationally.⁷ Escort services have the advantage of being covert and are therefore better tolerated by law enforcers and the community at large. However, escort sex workers are potentially exposed to violence from clients and may have less access to health care than brothel workers.

Private sex workers working alone or in small groups from “residential” premises are a significant sector of the industry in Australia, the United Kingdom, and many other parts of the world.^19,21,22 Private sex workers in developed countries, unlike doorway prostitutes, do not rely on passing trade but require their clients to make appointments by phone. Thus, although they often work alone they are able to control their work environment and preselect their clients to a considerable degree. It is difficult to measure the sexual health and welfare parameters of private workers because, like escorts, they work covertly.

Indirect prostitution

Prostitution is not always the sole or primary source of income for individuals, even in relatively impoverished settings. It can provide additional income for lowly or irregularly paid workers in other industries.¹⁰ In these cases the transaction may not be recognised as prostitution. Consequently the personal and public health risks may be greater than in the “direct” sex industry.³¹ During the Great Depression in Australia “amateur prostitutes” (sometimes part-time prostitutes, often any women engaging in casual sex) were blamed for a significant proportion of venereal disease in the community.^32,33 Similar blame was levelled at “good time girls” who accompanied foreign servicemen on wartime leave in Sydney.³⁴ Where a prostitution licensing regime exists “clandestinas” (unregistered sex workers) are more at risk than full time, registered sex workers.³⁵

There are some indirect sexual services (bondage and discipline, lap dancing, massage (table 2)) that involve little or no genital contact and therefore have little sexual health risk.³⁶ Even less risky are services such as telephone sex and the various forms of internet (virtual) sex which only become a public health concern if they precede an actual sexual relationship. These services are mostly confined to wealthier countries.

Other forms of indirect prostitution involve genital intercourse, but only after a previous transaction, such as the purchase of beer, or a massage, or some form of entertainment, has occurred.^37–39 These and other forms of opportunistic sex, including sex for drugs exchanges, can have major public health implications.¹³ Frequently, both the sex worker and the client view these transactions as unplanned, spur of the moment decisions. Therefore, sexual health precautions are unlikely to be observed and the participants may not recollect the acts as potentially hazardous “prostitution.” Often they will have consumed quantities of drugs or alcohol before having sex. Clandestine sex, whether commercial or not, often happens outdoors or in places without hygiene facilities and where haste overrides other precautions.

In “individual arrangements,” including “femmes libres”⁴¹ and sex workers with regular clients, the service providers may have a false sense of security based on a perception of freedom of choice.⁴³ However, their clients are frequently even less constrained. Sometimes, where customary relationships differ widely between neighbouring communities, one sexual partner may interpret a transaction as prostitution, while the other understands it as casual sex or short term companionate love.⁴⁴ Even more, in the case of survival or necessity driven transactions, the relative desperation and poverty of the sex worker can undermine basic health and safety considerations.¹¹

“Long time” arrangements, where a sex worker is engaged as a live-in companion (Bali), “minor wife” (Thailand), or “outside wife” (sub-Saharan Africa)^22,44,45 have pitfalls for both the client, who may believe he has avoided the risks of “commercial” sex by the arrangement, and the sex worker whose status at best is one of temporary concubinage and at worst is sex slavery. These arrangements infer large economic and power disparities between the sex worker and the client.

Other factors affecting the health and welfare of sex workers

The locational and circumstantial contexts of sex work are important in estimating the potential health hazards of prostitution, but there are other critical cross cutting factors. An important variable is the number of clients a sex worker sees during a typical working shift. High volumes of clients over relatively short periods are linked to high levels of STI and other poor health outcomes.^1,46 However, this is dramatically modified by the consistent use of condoms and the relative prosperity of sex workers and their community.^21,47,48 High numbers of clients associated with low income prostitution produces much worse outcomes.^30,49,50

Low income, in turn, is related to a number of factors. Sex workers in impoverished communities in developing countries earn little, and have very limited, if any, access to condoms and health services. Coerced sex workers are often forced to service large numbers of clients to maximise the profits of pimps and traffickers. Even without overt coercion, expenses imposed on sex workers (by minders, managers, corrupt officials, and court fines) may force them to work more intensely and for longer shifts than in more tolerant environments. Many sex workers have to see more clients because they are unable to charge an appropriate fee for services. Often very young and older sex workers are exploited in this way. Similarly, illegal, immigrant, homeless, mobile, and/or physically and socially isolated sex workers are less able to negotiate adequate prices for their services, particularly when many of their clients are similarly disadvantaged.^28,51,52

Compulsive and addictive behaviour involving drugs, alcohol, or gambling can motivate prostitution and increase the number of clients. As noted above the presence of these factors reduces the judgment and discretion of sex workers in health matters. They may equally be a reason for avoiding legal, health, and welfare services.

Trafficking and sex slavery

For centuries people have crossed borders to provide cheap labour including sex work.⁵³ Currently, these issues are matters of debate because of the global spread of HIV and the major labour migrations from eastern Europe, South America, and parts of Africa and Asia. Though travel and migration for the purposes of sex work are usually voluntary, sometimes they are not—giving rise to emotional language such as “trafficking” and “sex slavery.” Coerced prostitution is morally repugnant, but the current debate has failed to clarify the real issues relating to individual agency (choice) and the protection of human rights (including sex worker rights), in the context of trade globalisation and labour restriction.⁵³

Male and transgender sex work

Male and transgender sex work can assume any of the forms associated with female sex work. The client base is almost always male.^20,42 In spite of this many young and/or drug dependent male sex workers in wealthier countries self identify as heterosexual. Their clients, similarly, may be “gay,” “bisexual,” or “straight.”⁵⁴ Equally, many female sex workers self identify as lesbian. When male sex workers self identify as homosexual the distinction between work and play is sometimes blurred.^20,55 Typically located near resorts in poorer countries, young men—”bumsters” or “beachboys”—hire themselves to wealthy western women for social and sexual purposes. “Gigolos” are a half mythical upmarket form of bumster.⁴²

Child prostitution

Child prostitution is reviled everywhere though serious moves to reduce its prevalence through the active international pursuit of its clients and organisers, are relatively recent. Child prostitution is ubiquitous and can take any of the above forms.

CONCLUSIONS

In summary, prostitution varies enormously in its forms and social contexts. The health and personal safety of sex workers depends to a considerable degree on the context and location of their transactions and the intensity of their working life (table 3).

Almost everywhere there are laws designed to limit and control prostitution but they rarely achieve their desired effect. Laws against prostitution organisers may temporarily reduce the activity but also drive it into more covert forms.^5–7 Laws punishing prostitutes further reduce their power to protect themselves and leave them vulnerable to arbitrary and corrupt behaviour by officials.²⁹ Where prostitution is regulated by licensing, sex workers outside the system are doubly compromised as far as their health and safety is concerned, with potentially far reaching public health effects.^35,56

Commensurate with the economic basis of prostitution, health outcomes are generally better where sex workers have a higher status measured by their ability to earn a good income, be selective about their clients and their services, and be supported by adequately resourced health services and community based organisations.

CONTRIBUTORS

BD sketched out the original idea. Both authors pooled their research material; CH wrote the first draft which was then amended and modified by BD; CH was responsible for the paper’s final draft and submission