The welfare of female sex workers in low-income countries has attracted
significant attention in recent years. In line with human rights and development
goals, advocacy focuses on decriminalisation of sex work, attaining economic
rights, ending violence and improving sexual and reproductive health. Recent
studies by the IDS Sexuality, Poverty and Law programme have highlighted many
of these issues and placed them within the wider context and discussion around
sexuality and development. We call for further research and action in three
key areas, where evidence is needed to drive feasible, effective and measurable
initiatives that benefit sex workers, even in unfavourable legal, economic and
social conditions.UK Department for International Developmen

Overs, C

English

IDS OpenDocs

www.ids.ac.uk
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ISSUE 101 • SEPTEMBER 2015
“Despite 
their prolific 
presence, little 
information is 
available about 
the scale and 
impact of EEPs 
on outcomes 
such as HIV or 
gender-based 
violence and 
data about 
cost, outcomes 
or scale are 
rare.”
 Developing More Effective 
 Strategies for Sex Work, 
 Law and Poverty
Understanding the impact of 
economic empowerment 
programmes 
Research conducted in wealthy and poor 
countries alike overwhelmingly supports 
the assumption that poverty propels 
women and girls into sex work and 
renders sex workers more vulnerable to 
discrimination, exploitation and illness. 
Thus poverty alleviation programming 
and policy have important roles to play 
in both reducing the flow of women 
and girls into the sex industry and in 
strengthening sex workers’ economic 
capacities and increasing access to goods 
and services – in other words, ‘economic 
empowerment’.
Many types of rehabilitation and 
targeted economic empowerment 
programmes (EEPs) for female sex 
workers are operated in dozens of 
countries by organisations concerned 
with development, public health, gender 
and, perhaps most frequently, faith. 
Their methods vary but usually include 
activities such as vocational skills building, 
microcredit, social protection, income 
generating activities, counselling and 
saving cooperatives, among others. 
Despite their prolific presence, little 
information is available about the scale 
and impact of EEPs on outcomes such 
as HIV or gender-based violence and 
data about cost, outcomes or scale are 
rare. Conceptual frameworks, policy 
overviews or clear maps of how and 
where programmes operate are also 
lacking. In the absence of research 
about EEPs there is little technical 
information and few tools to guide 
best practice. This means that successes, 
suboptimal outcomes and failures of 
policies and programmes are not well 
understood. It can also mean that adverse 
events associated with rehabilitation 
and economic empowerment not 
systematically observed and documented, 
and opportunities to improve and expand 
effective strategies are missed.
The welfare of female sex workers in low-income countries has attracted 
significant attention in recent years. In line with human rights and development 
goals, advocacy focuses on decriminalisation of sex work, attaining economic 
rights, ending violence and improving sexual and reproductive health. Recent 
studies by the IDS Sexuality, Poverty and Law programme have highlighted many 
of these issues and placed them within the wider context and discussion around 
sexuality and development. We call for further research and action in three 
key areas, where evidence is needed to drive feasible, effective and measurable 
initiatives that benefit sex workers, even in unfavourable legal, economic and 
social conditions.
Sex workers are often encouraged to take part in 
economic empowerment programmes to help them 
exit sex work by requiring that they give up sex work 
while they learn new skills like hairdressing and 
sewing. Some of these programmes work but the 
majority of them fail sex workers to such an extent 
it is hard to imagine why such programmes are still 
considered as acceptable by some.
(The Global Network of Sex Work Projects) 
www.nswp.org/news/when-economic-
empowerment-programmes-fail-sex-workers
Promoting legal recognition 
The limited research available about sex work 
and citizenship indicates that rules that govern 
administrative matters and confer status 
on people as citizens, workers and family 
members have a significant effect on the 
circumstances in which sex is bought and sold 
and how sex workers live. Lack of citizenship 
or legal personhood, which is usually 
experienced as the absence of identification 
documents, appears to be associated with 
poor outcomes. If this is true, it points to 
opportunities to change policy and practices 
that could significantly improve the ability of 
sex workers to work in the safest possible 
circumstances; to house and educate their 
children; and to avoid violence, exploitation 
and discrimination. 
Birth registration is usually the first step in 
gaining recognition of legal personhood. 
It is a crucial gateway to other forms of 
legal recognition and citizenship, including: 
passports, marriage licenses, naturalisation 
and enrolment in taxation, electoral and 
other civic registers. Perhaps the most 
recognisable example of adults lacking legal 
personhood is undocumented migrants. In 
some places identity is recognised by local 
government and it is lost if the person 
moves to another place within the same 
country. Where people do not enjoy the 
recognition of law they are vulnerable to 
inappropriate law enforcement and typically 
do not have access to health care, social 
services, accommodation, financial services, 
communications, humanitarian aid and 
education. This has a particular impact on sex 
workers ‘without papers’ who must use other 
strategies to obtain goods and services, or 
do without them. Thus poverty, vulnerability, 
exploitation and illness are exacerbated by 
lack of legal status, which frequently extends 
to sex workers’ children who are, in turn, 
denied vital resources and incentivised to 
enter the sex industry.
Surprisingly, in this context, associations 
between lack of legal personhood and 
health and welfare outcomes for sex workers 
have barely been studied. Nevertheless the 
value of gaining legal recognition has been 
identified by some frontline services that 
help sex workers to obtain the identification 
documents needed to establish legal 
personhood. Because people must complete 
application forms and prove, for example, 
that they have a formal residential address or 
work in the formal economy it is frequently 
a difficult process, especially for sex workers 
who are not literate, are mobile or live in 
informal settlements. 
As a result of an IDS Sexuality, Poverty 
and Law Evidence Report on sex work and 
poverty in Ethiopia, a non-governmental 
organisation (NGO) that operated several 
drop-in centres for sex workers throughout 
the country began helping users of its services 
to apply for them. The director of the NGO 
reported that identity documents have been 
obtained for many sex workers with some 
positive outcomes. He said that the requests 
for identification documents had been 
received more favourably by authorities than 
anticipated. Evidence like this suggests that 
ensuring sex workers legal personhood is a 
politically feasible strategy and could effectively 
address sex workers’ vulnerability in low-
income countries.
Planning for the impact of biomedical 
HIV prevention
As a result of scientific advances the focus of 
HIV programmes is shifting from education, 
condoms and the treatment of sexually 
transmitted diseases to preventing HIV 
transmission by providing anti-retroviral 
medication (ARVs). These medications prevent 
transmission in two ways:
1. When used as treatment in HIV-positive 
people ARVs reduce the presence of 
the virus to a level where it cannot be 
transmitted. This is known as Treatment as 
Prevention (TasP).
2. When taken by HIV-negative people 
ARVs significantly reduce the chances of 
contracting HIV through sex. 
While scientific developments have the 
potential to reduce HIV infection globally or 
even end the epidemic, they raise significant 
challenges for female sex workers. As well 
as affecting how health services are provided 
DEVELOPING MORE EFFECTIVE STRATEGIES FOR SEX WORK, LAW AND POVERTY ISSUE 101 • SEPTEMBER 2015 www.ids.ac.uk
“Where people 
do not enjoy 
the recognition 
of law they are 
vulnerable to 
inappropriate 
law enforcement 
and typically do 
not have access 
to health care, 
social services, 
accommodation, 
financial services, 
communications, 
humanitarian aid 
and education.”
DEVELOPING MORE EFFECTIVE STRATEGIES FOR SEX WORK, LAW AND POVERTY ISSUE 101 • SEPTEMBER 2015 www.ids.ac.uk
“While scientific 
developments 
have the 
potential to 
reduce HIV 
infection globally 
or even end the 
epidemic, they 
raise significant 
challenges for 
female sex 
workers.”
to female sex workers they will impact on 
the resourcing of social programming and 
advocacy. 
A key challenge is how to ensure that 
universal HIV testing of sex workers does 
not reduce confidentiality or increase 
discrimination and abuse. Another challenge 
is that because pre-exposure prophylaxis 
(PrEP) is not 100 per cent effective against 
HIV and does not protect against sexually 
transmitted infections (STIs) or pregnancy it 
must be used with condoms, not instead of 
them. But in many settings it is likely that 
sex workers will not be able to continue to 
insist on condom use as demand rises for a 
product perceived as making ‘flesh-to-flesh’ 
sex safe. Where that occurs HIV risk will 
remain or increase (depending on numbers 
of clients and prevalence of untreated HIV 
in sexual partners) and STIs, hepatitis and 
unplanned pregnancies would increase. 
Hence, new HIV prevention has been dubbed 
‘combination prevention’ to encourage sex 
workers to both take PrEP and refuse sex 
without a condom. However, this is sure to 
be difficult, particularly where clients and sex 
business owners decide what methods are 
used to protect sexual health rather than sex 
workers. 
Concerns have also arisen about drug 
resistance and toxicity, meeting new 
information needs and the cost of products. 
Access to clinical services is also a key issue 
since sex workers who take PrEP must 
regularly access a qualified doctor who can 
prescribe medicine and monitor its effects. 
In contrast to condoms and education 
which could be distributed freely by staff 
with basic training, scaling up testing and 
administering prescription medications 
means that highly qualified service providers 
will need to identify, track and retain large 
populations of sex workers as patients. 
This may be unrealistic where funds are 
unavailable, where health systems are weak 
and/or sex workers are excluded, and the 
need to identify individuals raises ethical 
challenges where the resources or will to 
protect patients are lacking. Raising the 
bar for individuals’ access to HIV prevention 
has clear potential to leave behind migrant 
and mobile sex workers, those who live 
in remote areas or lack legal personhood 
and other groups of sex workers who are 
unable or unwilling to access or manage 
prescription medicine.
For sex workers to benefit from biomedical 
HIV prevention and treatment, strategies 
must be in place to avoid adverse events 
and human rights abuses. They must ensure 
that medications are properly prescribed and 
adhered to and that STIs, HIV or unwanted 
pregnancies do not increase even in the most 
vulnerable sex workers. To achieve this it is 
crucial that efforts continue on reducing 
the factors that leave sex workers powerless 
and obstruct current HIV programming – 
discrimination, exclusion, cost, violence, loss 
of livelihood, lack of nutrition and housing 
and poor treatment by health-care workers. 
This raises the question of how governments, 
development agencies and NGOs can 
reconfigure resources allocations to ensure 
that work towards human rights, social and 
economic goals that was previously funded 
from HIV budgets continues and grows 
despite the shift toward medicalised HIV 
prevention. 
IDS POLICY BRIEFING ISSUE 101 • SEPTEMBER 2015 www.ids.ac.uk
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Further reading
Bekker, L.; Johnson, L.; Cowan, 
F.; Overs, C.; Besada, D.; Hillier, 
S. and Cates, W. (2015) 
‘Combination HIV Prevention 
for Female Sex Workers: What 
is the Evidence?’, The Lancet 
Series on HIV and Sex Work 
385: 9962
Global Network of Sex Work 
Projects (2011) New Prevention 
Technologies and their Implications 
for Sex Workers, Briefing Paper 
4, Global Network of Sex Work 
Projects
Overs, C. (2014) Sex Workers, 
Empowerment and Poverty 
Alleviation in Ethiopia, IDS 
Evidence Report 80, Brighton: 
IDS
Overs, C. and Loff, B. (2013) 
‘Towards a Legal Framework 
that Promotes and Protects Sex 
Workers’ Health’, Health and 
Human Rights 15: 1
Credits
This IDS Policy Briefing was 
written by Cheryl Overs, 
Visiting Fellow at the Institute 
of Development Studies, and 
was edited by Carol Smithyes. It 
was produced as part of the IDS 
Sexuality, Poverty and Law 
programme, supported with UK 
Aid from the UK Department 
for International Development.
The opinions expressed are 
those of the author and do not 
necessarily reflect the views of 
IDS or the UK government’s 
official policies. 
Readers are encouraged to 
quote and reproduce material 
from issues of IDS Policy Briefings 
in their own publication. IDS 
requests due acknowledgement 
and quotes to be referenced as 
above.
AG Level 2 Output ID: 604
© Institute of Development Studies, 2015 
ISSN 1479-974X
Policy recommendations
Decriminalise sex work 
Amnesty International is the latest of dozens of respected human rights and health 
organisations to join the consensus that sex work should be decriminalised because 
criminal law forms the single greatest barrier to sex workers attaining justice and 
dignity. Law reform is a primary recommendation because it plays a crucial role in 
determining how effective any strategy can be. This means that until laws against 
sex work are removed programmes and policies that are viable despite unfavourable 
conditions must be identified and implemented.
Economic empowerment programmes
Policymakers, donors and implementers of EEPs need data and guidance to inform policy 
and programming for sex workers that is ethical, effective and that significantly alleviates 
poverty and its impacts on sex workers and their families. Next steps should include:
• Mapping existing economic empowerment programming.
• Identifying the evidence, and evidence gaps, around targeted poverty alleviation 
strategies for sex workers.
• Conducting research in multiple sites to identify the impact of various methods 
on multiple outcomes, including unintended consequences.
• Developing a conceptual framework, practical guidance and tools such as protocols 
for measuring outcomes for sex workers of various ages and backgrounds.
Legal recognition 
The notion that increasing sex workers’ legal recognition is a cost-effective and 
politically feasible intervention that can improve sex workers’ economic, health and 
social status should be tested by documenting existing interventions and conducting 
research to explore correlations and associations between increased citizenship and 
specific outcomes for sex workers and their families. 
If it is proven that obtaining legal identification documents improves sex workers’ 
lives and reduces vulnerability, materials should be developed to encourage and 
guide NGOs and governments to work cooperatively to implement action to 
recognise sex workers’ legal personhood. 
Biomedical HIV prevention and care 
Resources should be made available to support independent research and advocacy 
that aims to ensure that biomedical HIV care and prevention effectively reduces HIV 
among sex workers without generating adverse consequences. This should include:
• A global review of the evidence on biomedical HIV prevention and care for 
sex workers in low-income countries. The review should identify evidence and 
evidence gaps; policy and programming that can best support biomedical HIV 
treatment for sex workers; and any strategies that are being developed, or are in 
place, to address potential barriers and reduce associated risks. 
• Development of protocols for monitoring a broad set of outcomes of biomedical 
HIV care and prevention for sex workers. 
• Monitoring the impact of new approaches to HIV prevention on interventions that 
aim to empower sex workers economically and socially. This information should be 
used by development and public health agencies to ensure that effective work in 
these areas is not undermined or reduced as a result of resources shifting toward 
providing clinical HIV services. 


Developing More Effective Strategies for Sex Work, Law and Poverty

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