Internationally, the official public health position on the decriminalization of the sex trade is clear. The World Health Organization, Amnesty International, Human Rights Watch, UNAIDS and the Global Commission on HIV and the Law agree that decriminalization is the right choice for every country in the world. Research from countries as diverse as Kenya, New Zealand, South Africa and Canada suggests that decriminalizing sex trafficking can reduce HIV, prevent violence and reduce stigma. What else can be said on this issue, at least from a public health perspective? Greater condom use has been observed in legalized and decriminalized contexts. The Van Veen et al. study reported consistent condom use in 81% of participants [106]. The reduction in condom use in some criminalized jurisdictions may be partially influenced by the use of condoms as evidence of criminal activity by law enforcement, creating barriers to condom use or use [144, 145]. It may also explain some of the higher prevalence rates of STIs reported in partially criminalized settings [67,69]. For example, studies in these settings have found that sex workers are under greater pressure from clients to engage in unprotected sex [67] and offer higher payments for condomless sex [66]. Levy and colleagues [142] also note a low supply of condoms in Sweden by designated prostitution units, partly because of the perception that the provision of condoms facilitates sex work, which was incompatible with the goals of Swedish state abolitionism. Nations are divided on how best to combat prostitution.
Many forbid it; some, including Canada and Sweden, penalize customers and others, such as Germany and New Zealand, legalize or decriminalize it completely. This decriminalization of indoor prostitution in Rhode Island happened more or less by accident. In 1980, in an effort to reduce the prevalence of street prostitution, Rhode Island lawmakers amended a sentence in a law describing the accuracy of prostitution by explicitly prohibiting street prostitution, but inadvertently removing the phrase describing indoor sex work. This loophole was exploited and exposed in 2003 when a district judge dismissed prostitution allegations against a group of massage parlor employees because their actions did not fall within the existing definition of prostitution. Indoor prostitution was criminalized again in 2009, a natural experiment in the health effects of legal prostitution. Studies conducted in environments where sex work was criminalized and partially criminalized frequently reported epidemiological data such as STI and BBV prevalence, vaccination rates, and drug use [78,79,80,82,83,84,85,86,109,111,112,122,123]. However, it was found that epidemiological data for partially criminalized studies were reported more frequently in relation to social influences such as experiences of violence [41,46], stigma [44] and sexual risk behaviours [66,67,69,88,89,101,105,121,127]. Studies in settings where sex work has been legalized have often reported on the impact of legislation on improving sexual health [52,61] and mental health outcomes [60,103]. Studies in contexts where sex work has been decriminalized have shown that sex workers are likely to exhibit health care behaviours [18,29,57]. These results were compared to a number of studies that identified problems with access to and use of health services in other settings, including partially criminalized [45,72,116,117,119], criminalized [113,114] and “Nordic model” [65] attitudes. A study explicitly comparing access to health services across decriminalised, legalised and partially criminalised jurisdictions in Australia found that sex workers in partially criminalised environments had the worst health and safety outcomes, with greater availability of public sexual health clinics in legalised jurisdictions and greater investment in health promotion programmes. Health and safety measures in decriminalized and regulated environments [27, 102].
But Tsitsi Matekaire of women`s rights group Equality Now said it was wrong to view prostitution solely as a health issue, adding that decriminalization was not the best way to protect women. In the United States, prostitution has long been made illegal for moral, safety and health reasons. Recently, states like New Hampshire and California have challenged these laws, opening the issue to public debate. The effects of legalizing prostitution are still largely unknown, as they have been studied primarily in controlled environments. Observing the impact of legalized prostitution on a society can provide evidence to legitimize or delegitimize public health and safety concerns. However, for empirical effects to be observed, legislators must first relax laws prohibiting prostitution, which is politically unenforceable as long as prostitution remains taboo. This review revealed experiences of stigma, discrimination and marginalisation in countries with different legislations, with experiences of stigmatisation associated with reduced use of health services. For example, results from New South Wales suggest an improvement in the health and safety of the sex industry, in addition to a reduction in the financial burden on the criminal justice system since the introduction of decriminalization in 1995 [22]. It is also argued that decriminalisation has the potential to normalise the role of sex work, thereby reducing stigma and discrimination among sex workers [26] and improving the accessibility of health services [5].
Previous studies suggest that the experience of social problems such as stigma, marginalization and discrimination may persist for some time after legislative reform [18,24]. This may explain the presence of stigma in countries where decriminalization and legalization have been abolished, where systemic and historical marginalization has affected access to and use of health services [103,118,119]. This finding suggests that the experience of discrimination and stigma by sex workers may take time to improve decriminalization. Established cultural norms, including societal attitudes and behaviours towards sex work, can only change slowly, particularly given the historical context of criminalization [13]. This underscores the pervasive nature of stigma [150], which requires further investigation through more robust study designs that include an analysis of the political, social and cultural factors that shape the experience of stigma and discrimination. In addition to legislation, specific interventions and measures are needed to improve this social health outcome. The authors chose to assess the incidence of gonorrhea as a measure of public health effects because of its strong association with heterosexual contact and prostitution. Previous studies have argued that decriminalization could increase the incidence rate of gonorrhea by increasing the potential exposure of high-risk sex workers, but could also reduce the incidence rate by bringing new low-risk sex workers to market, thereby diluting the potential for infection. The results showed that decriminalization resulted in a 40% decrease in the incidence of gonorrhea among women and a 30% decrease in reported rape offences. From 1999 to 2003, the rate of reported rape in Rhode Island was about the same as in the rest of the country.
However, during the period when indoor prostitution was legal, the rate of reported rape offenses fell below historical rates in Rhode Island and average rates in the United States. The authors found no evidence of changes in police employment, data collected, or data definitions during this period that would affect these outcomes.