The sex conundrum

When politicians or pundits pontificate on sex work they make sweeping assumptions unsupported by the evidence, says Belinda Brooks-Gordon, who is seeking to revamp Liberal Democrat policy

Justice and Civil Liberties on Sex Work in Contemporary International Human Rights Law

To fulfil obligations in international law State parties have to take the issue of human trafficking seriously. The United Nations Committee on the Elimination of Discrimination Against Women (CEDAW) provides General Recommendations (GR) to member states on the interpretation of the Women’s Convention. In 2018 the CEDAW Committee started to develop a GR on trafficking in women and girls in a process planned to conclude in 2020. The first stage towards this was through the publication of a Concept Note to serve as a basis for dialogue during the two-year international consultation period. The Concept Note is a vital link in a textual chain because it frames the policy problem and actively constructs its own ‘documentary reality’. This article provides a critical analysis of the CEDAW Concept Note on the grounds that such analysis provides an understanding of its discursive construction of trafficking, migrant labour and sex work, by an institution responsible for international jurisprudence on human rights. Analysis of the Concept Note explores the documentary constructions including narratives that merge adult women with girls, the symbolism of exploitation, the silencing of scientific research, the elision of sex worker voices, and sex work as work. The analysis leads us to conclude that the General Recommendation should define what counts as ‘exploitation’, and ‘forced labour’, and address the growing international recognition of best evidence on the wider impact of sex work laws, in order that legal framing and constructions of sex trafficking are not erroneously used to curtail rights of sex workers

Production, income, and expenditure in commercial sexual activity as a measure of GDP in the UK national accounts

Executive summary: This paper reports the economic activity of sex workers for its inclusion into gross domestic product (GDP) for the UK National Accounts. Markets in consenting but nonetheless illicit activities, including commercial sexual activity and drugs, were incorporated into figures for the UK National Accounts for the first time in 2014. This was to ensure comparability of the Gross National Income (GNI) measurements across EU countries. We evaluate the methods and data used to calculate prostitution in the first ONS (2014) analysis and explore the constraints and limitations in the calculation of prostitution data. We provide an updated figure for the number of sex workers using monitoring data from NHS specialist services and a using a standard methodology that has been employed by HIV prevention organisations across Europe to supply estimates of the number of sex workers in the UK as well as income and expenditure in various sex work markets in which both parties are voluntary participants. The London and regional markets are sectored separately to take account of the denser market in the capital, and to reflect the composition and differential pricing and working practices of sex workers in different sectors based on location and gender. Trying to estimate informal covert markets and activities presents an immense methodological challenge. Not surprisingly there have been few attempts to estimate this hidden part of the UK economy in the peer-reviewed literature or from quality sources. To date only Kinnell (1999), and Cusick, Kinnell, Brooks-Gordon and Campbell (2009) have attempted it in the UK. There remain significant limitations and levels of uncertainty, but we provide a model that is based on primary and secondary data from national and regional governmental and NGO services, to develop a model of the non-observed economy (NOE) which is scalable, simple, and with more explanatory power than previous attempts, to create a framework for the future calculation of this activity in the UK National Accounts

The Chemsex ‘Consent Ladder’ in male sex work: perspectives of health providers on derailment and empowerment

Sexualized substance use or ‘chemsex’ is a key element in the syndemic of violence and infection in gay, bisexual, and other men who have sex with men. Chemsex is more prolific amongst men who have sex with men but is also associated with high risk behaviours that can negatively impact on health and wellbeing in heterosexual, bisexual men and women, and in homosexual women too. This qualitative study investigated perceptions and experiences of chemsex, motivations, cisgender male sex work, consent, economic exploitation, and ways to address and reduce harms. We conducted semi-structured interviews with health care providers and their clients—including sex workers and their customers (n = 14) between the ages of 28 and 46 years following a purposive sampling strategy. Interview topics included perceptions and experiences of chemsex use, reasons for drug use and chemsex, and proposals to address harms associated with chemsex in the UK. Interviews were audio-recorded, transcribed, coded, and analysed using Grounded Theory. The findings revealed a stepwise process of chemsex use in a ‘ladder of consent’, whereby the process starts with willing participation that is both highly pleasurable and controllable. Sexual polydrug activity often descended in rungs so that lines of consent became blurred, and even broken, resulting in physical detriment and financial exploitation. Strategies for elevation back up the consent ladder also emerged. The findings clarify the conditions of willing participation, the stepwise relationship to exploitation, and the support strategies that help re-empower individuals whose lives get taken over by chemsex, including peer-to-peer support, poly-centres, and smartphone apps to climb back up the consent ladder to improve the health, safety, and social rights of sex workers

Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS: In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS: Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION: Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING: UK National Institute for Health Research Health Technology Assessment

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Bellwether citizens: the regulation of male clients of sex workers

Dangerous and discriminatory new provisions against sex workers' clients have repeatedly been put before parliament in England and Wales. Female ministers keen to punish clients of sex workers eagerly supported the Bill. However, while sex work has become a rights issue it is no longer just about women's rights. Diverse and multiple sexualities and working practices see gay, trans or bisexual workers selling sex to a diverse range of lesbian, gay, trans, and straight clients who may be able-bodied or disabled. This article critically examines the regulation of clients of sex workers, explores the current legislation against them, and reviews recent research evidence. The ideas that inform policy will be discussed along with the various policy approaches. The latest move to criminalize clients in the Policing and Crime Bill 2009 will be discussed along with the spectre of trafficking, used to scapegoat clients by a government which has undermined civil liberties and the fundamental concepts of a free society