Sex workers access to health and social care services: A social justice response

Abstract

This research explores service providers’ views on the barriers that prevent women in the sex work industry in Ireland from accessing co-ordinated health services. A purposive sample of eight service providers in the field of women’s health and social care in the West of Ireland were selected and interviewed for this study. The service providers were asked about their perception of the barriers of sex workers accessing health and social care services. Using thematic analysis, three key themes were identified: (1) lack of knowledge of women’s involvement in sex work; (2) identified barriers to health services; and (3) legislative and policy barriers to providing supportive services. While the service providers acknowledged that they do not knowingly provide services for sex workers, they all recognise that some of their service users are at risk of, and potentially are, involved in sex work. Yet, they were able to identify some of the barriers sex workers face when accessing their services. All these barriers were the result to the services’ limited capacity to support women engaging in sex work. At the time of data collection, the legislative context meant that selling sex under certain conditions was outside the law. This study highlights the consequences that criminalisation can have on the health of sex workers and the need for a paradigm shift in existing health and social care services. In this paper, we propose that a social justice rather than a criminal justice approach has the potential to address sex workers’ right to access appropriate health care. This paper gives due recognition to marginalised women, and advocates for better provision of services for women in the sex industry, while considering the new legislation of 2017.

Keywords

Sex work health health and social care services social justice

Introduction

Sex workers across the world experience exclusion from health and social care services and their social support needs predominantly remain unmet (Howard, 2018). It is difficult to estimate the number of women working in the sex industry in Ireland due to the clandestine nature of this activity and the lack of empirical evidence to establish a baseline (Ward, 2010), but we do know that women involved in sex work in the Republic of Ireland (hereafter Ireland) work primarily indoors, move around the country, and some of these are migrants, with precarious legal status (Ward and Wylie, 2010). Women involved in the sex industry, both indoors and on the street, oftentimes experience family breakdown, addiction, mental health issues, poverty and violence (Nelson et al., 2010; Sanders and Campbell, 2007). While there are specialised health services throughout the country to address such concerns, these are not specific to sex work and sex work-related experiences. Sex workers tend not to disclose their involvement in sex work to service providers (Sanders, 2013). International research shows that there is a strong correlation between fear of the stigma of prostitution, fear of being reported to authorities, employers and colleagues, and potentially for some such as migrants, deportation and sex workers non-disclosure of their status (Campbell, 2018, see also article by author in this themed issue). Such fears create isolation and marginalisation, which are often the root cause of sex workers remaining excluded from health services and the consequent mental health challenges they face (Sanders, 2007). This is of concern, as evidence suggests that stigma and social censure due to others’ attitudes to prostitution/sex work contributes to poor mental health outcomes and well-being (Hubbard and Prior, 2012). The impact that such stigma has on the health of sex workers is further magnified in the context of a legal system that criminalises the sex worker (FitzGerald and McGarry, 2018).

In 2017, the Government of Ireland amended the criminal code and introduced the Criminal Law (Sexual Offences) Act 2017. When the Act came into force, it criminalised the purchaser of sex only. While prostitution has always been legal in Ireland, several activities around it, such as brothel keeping, were in breach of the law – and remain so after the 2017 Act came into force. For example, the law has always prohibited ‘soliciting or importuning another person in a street or public place for the purpose of prostitution’ (this offence applies to the sex worker and client). Furthermore, it prohibits ‘loitering for the purpose of prostitution, organising prostitution by controlling or directing the activities of a person in prostitution, coercing one to practice prostitution for gain, living on earnings of the prostitution of another person, and keeping a brothel or other premises for the purpose of prostitution’. This meant that prior to legislative change in 2017, disclosing involvement in sex work could result in prosecution and criminal proceedings against the sex worker. Those who supported the new legislation and the politicians who championed it believed that criminalising those who purchase and not those who sell sex would, to some degree, protect women involved in sex work (FitzGerald and McGarry, 2016). Yet, at the time of writing and two years after the introduction of the Act 2017, no additional infrastructure to address the psychosocial health needs of sex workers was developed, and the existing health and social care services were not extended to address their needs. Given that the supporting system available for women in sex work has not been developed, the barriers to health that women in sex work experience still exist and their needs are yet unmet (Hubbard and Prior, 2012). This paper explores these barriers as seen from the perspective of service providers, who are supposed to be at the forefront of meeting the health and social care needs of vulnerable women, and by that, to enact social inclusion policies.

In general, social inclusion policies seek to address the exclusion of marginalised groups in society (Benoit et al., 2018). Despite Ireland’s inclusion policy and National Strategic Framework for Health and Social Care Workforce Planning Strategic Framework (hereafter the Framework), women in Ireland’s sex industry remain on the periphery of social policy (Benoit et al., 2018). The government’s failure to recognise sex workers’ health needs is stark at the policy level. For example, The National Sexual Health Strategy 2015–2020 (hereafter Strategy) details both the legal and social framework that seeks to address sexual health and wellbeing in Ireland. Although the Strategy references sex workers within the context of ‘groups of people who are at risk of and/or are vulnerable to experiencing negative sexual health outcomes’ (Department of Health, 2015: 3–4), it does so by classifying all sex workers as ‘vulnerable’ and ‘at risk’ who ‘require specific interventions to attain and maintain sexual health’ (Department of Health, 2015: 3.4). In framing sex workers as inevitably victims of violence or coercion such as sex trafficking, the Strategy does not capture the complexity and diversity of sex workers and the circumstances that lead them to sex work. While the National Sexual Health Strategy's recognition of sex workers’ health needs is important and commendable and while it cites as one of its objectives, the need to ‘develop an evidence-informed response to targeting those most at risk of negative sexual health outcomes’ (Department of Health, 2015: 3.16), it does not elaborate on how that will be realised in practice. Therefore, we argue that currently, the Strategy is a barrier both to sex workers accessing health services and health care professionals’ ability to address those needs in an appropriate and sustainable way. We argue this because the Strategy only addresses those identified to be at risk, or vulnerable sex workers seeking exiting strategies from sex work, and not the needs of other women in the sex industry.

In order to better understand the barriers as experienced by health care providers, we interviewed a small sample of health and social care providers and asked them about the challenges they face when trying to address the needs of sex workers attending their services. We start by examining the perceived needs of sex workers as understood by health and social care service. This was then analysed in the context of the structural and social barriers faced by women in the sex industry when trying to exercise their right to health and health care, in a manner that is non-judgemental. The literature suggests that stigma and discrimination, violence and punitive legal and social environments are key determinants to limit the availability, access and uptake of services, care and support for sex workers (UNAIDS, 2014), and in this study, we tried to see to what degree this is reflected in the views of the health and social care providers that took part in the study. We focused on this group as Irish health service providers work regularly with marginalised groups in Irish society and are often sex workers’ first point of contact with the health care service. Hence, if they fail to support sex workers, they embody Ireland’s failure to institutionalise a national framework that supports relevant inclusion policies for those on the margins of Irish society like sex workers (Benoit et al., 2018). Interviewing the experts that work on the ground with sex workers can provide an insight into the barriers faced by sex workers from a point of view that is rarely being examined.

To further our understanding on the challenges of sex workers, and the potential opportunities that exist in the services, this paper will delve into the social justice literature. The literature on social justice allows us to identify alternative ways of locating sex work discourse other than current legislative solutions, given the evidence that legal solutions exclude health and social care infrastructures (Sweeney and FitzGerald, 2017; Ward and Wylie, 2010). We believe that a social justice perspective is best suited for addressing access to health and social care services. The paper presents social justice literature, followed by the methods and findings of this paper. We will then discuss the findings within the context of social justice.

Literature review

Sharron FitzGerald and Kathryn McGarry in their book entitled, Realising Justice for Sex Workers: An Agenda for Change (2018: xv) identified social justice as ‘the idea that everyone deserves parity in terms of opportunities, political rights and distribution of wealth and privilege to participate as peers in social life and lead fulfilling lives’. A social justice response, therefore, requires more than just assessing the nature of distributive justice–ensuring all members of society share in economic prosperity–but it demands that we recognise marginalised groups as member of society (Fraser, 2007; Nussbaum, 2007; Weitzer, 2010).

This framing of social justice has traction when we consider sex workers’ right to access state health services (FitzGerald and McGarry, 2018; Kempadoo et al., 2015; Nussbaum, 2007; Weitzer, 2007). In the context of sex workers in Ireland, using a social justice lens would open a conceptual space that would empower us to find new ways to implement a fair distribution of resources for their health and welfare needs, as well as properly recognising sex workers personhood as members of society who are often marginalised and isolated (Nelson et al., 2010; Scoular et al., 2007). In relation to Irish sex workers, we find that a conceptualisation of social justice based on the principles of ‘parity of participation’ where ‘justice requires social arrangements that permit all members of society to interact with one another as peers’ (Fraser, 2007: 27) provides an important conceptual tool to address the experience of sex workers, their marginalisation from health services because of various identified barriers, and the government’s, and consequently health care services’ failure to recognise them as autonomous participants who can shape their status within the culture constructed around them (FitzGerald and McGarry, 2018). Social justice discourse helps us go beyond arguments regarding prejudice, marginalisation, victimhood or blame, to a context where we can begin to ‘think’ social justice as an integral part of health care for all marginalised groups and begin to implement and support practical steps in Irish social policy that will lead to non-judgmental health care for sex workers (Lazarus et al., 2012; Sanders and Campbell, 2007).

The World Health Organisation (WHO, 2015) has offered guidance to governments regarding the rights of sex workers in the context of the human right to health; however, Ireland is still tackling demand for sex work through criminalisation which they believe will solve the problem of ‘harm’ in prostitution (FitzGerald and McGarry, 2018; Sweeney and FitzGerald, 2017; Ward and Wylie, 2010). By contrast, the WHO proposes states should seek to limit the harmful effects of national laws on the health, safety and rights of people engaged in sex work (WHO, 2015). Thus, while Irish neo-abolitionist groups like the Turn Off the Red-Light campaign believe that criminalisation of sex purchase will eradicate sex work, this does not solve the fundamental socio-economic problems that drive women into the sector in the first instance (Scoular and O’Neill, 2008). In fact, this position only further compounds sex workers’ invisibility and inability to address their health (Sanders, 2013); as the WHO (2015) observes, in such a context, sex workers are likely to face poor treatment, and experience discrimination and stigmatisation by health care providers. Consequently, we argue that Ireland requires a social justice paradigm to address the outstanding, institutional, cultural and on-going concerns of exclusion from health and social care services for sex workers, which our empirical research detailed in the next section reveals.

Methods and sources

There are several agencies in the West of Ireland providing a range of health and social care services for women that are homeless, migrants or suffer from addiction and domestic violence. The identified services address the health and social care needs of women experiencing homelessness, addiction and migration. The literature identified similar experiences for sex workers (Sanders and Campbell, 2007). These services notwithstanding, no dedicated or specialised unit exists that are equipped to include sex workers’ psychosocial needs in its service provision throughout the country. The Women’s Health Project is a dedicated health service, funded by the Health Service Executive to support women in the sex industry. However, at present, this service only exists in Dublin, Ireland’s capital city, and therefore access to this service is not always an option for sex workers in other parts of the country. Our study examines to what degree these services address the needs of sex workers, and if they do not meet them, what are the barriers as perceived by the service providers.

The study used a qualitative method approach. We invited one representative from each of these agencies to participate in this study. All those invited agreed to participate, resulting in a purposive sample of eight service providers. While the findings are from a small qualitative sample from the West of Ireland, our findings reflect the evidence presented in both national and international literature, which may suggest that our findings are transferrable to other societies which share similar health service infrastructures and geographical make-up. We conducted face-to-face semi-structured interviews with the eight participants in summer 2014. Each interview lasted between 30–60 minutes. Before commencing each interview, the interviewer answered participants’ questions and arranged a time and location convenient for them to conduct the interviews. Each participant read and signed a standard consent form prior to interview. No issues of consent emerged. The interview topic guide was developed based on the initial research question: What are the needs of women involved in sex work? The topic guide explored service providers’ experiences and knowledge of sex workers and their service’s responses to these women. The topic guide was a ‘living document’ and evolved from interview to interview depending on what came to light during the discussions (Scalabrini, 2013). Each participant worked with women experiencing different needs. Moreover, each of the services had their own unique approach to supporting service users depending on their individual needs and the purpose of the service and its resources. All interviews were audio recorded and transcribed verbatim and analysed using qualitative content analysis (Bazeley and Jackson, 2013). The transcriptions did not include the name of the service provider or the agency, and the audio recordings were destroyed once the transcription was confirmed to ensure the confidentiality of the participants and protect their anonymity.

Each transcript was reviewed using qualitative content analysis to identify emerging themes from the data, which were then organised into specific themes. Coding and analysis were completed using NVivo software by the lead qualitative expert on the study. Coding, analysis and interviews occurred in parallel so that early findings could inform later interviews (Strauss and Corbin, 1998). The coding process involved familiarisation with the qualitative data through repeated reading and note taking of the transcribed data from the interviews, generating initial codes, searching for themes, reviewing themes and finally defining and naming themes. The results are structured in terms of the main themes which emerged from the interviews (Braun and Clarke, 2006). Illustrative quotes are provided to highlight the participants’ experiences (Corden and Sainsbury, 2006). The study obtained approval by the University Ethics Committee.

The thematic analysis which we discuss below highlights a few reoccurring concerns that were raised by the service providers we interviewed as part of this study, and these were divided into themes for further study. These themes were: (1) lack of knowledge of women’s involvement in sex work, (2) identified barriers to health services from service providers’ perspective and (3) legislative and policy barriers to providing supportive services. We will now discuss these themes.

Lack of knowledge of women’s involvement in sex work

Participants in this study were asked to identify the barriers to health and social care services for women involved in sex work. While the majority of service providers, with the exception of one, stated that they did not know for certain whether service users were involved in sex work, however, they all assumed that some of the service users were involved in sex work. ‘I’ve had reports from residents who have been approached, or who have reported to me they’ve been approached by Irish men asking them to hook them up with women … ’ (Migrant Services).

Yeah absolutely, well both … we’ve had experience of having suspicions around em, people being involved in prostitution based on I suppose their lifestyle, their em, you know what they’re doing, their comings and goings, their mobile phone use, just from our observation, you know, getting phone calls at very late in the evening and leaving and coming back to the hostel so that they’ve met people, but it’s been, you know suspected that it’s … (Migrant Services)

Participants identified some signs that could indicate individuals’ involvement in sex work, for example, homelessness, addiction and legal status of the woman if she was a migrant. ‘I mean you’re not able to access social welfare unless you have an address so many women who come to us wouldn’t have payments set up or they’ve been without payments for some time’ (Homeless Services). The service providers identified these as risk factors that could lead individuals to turn to sex work to generate income, or as conditions that could make some women vulnerable to those who organise sex work. For example, a service provider addressing homelessness discussed the connection between homelessness, addiction and lack of fixed home address.

Another service provider working with foreign national women discussed a servicer user’s involvement in sex work: ‘When I was working in the Asylum Seeker Clinic, there was certainly one woman who said she used to be a prostitute, and she was a [child prostitute]’ (Migrant Support Services). In addition, this service provider identified service users accessing a hotel regularly, or travelling frequently throughout the country, which she suspected was for the purpose of meeting with clients:

… [A]nd it wasn’t just her that I had seen at that hotel it was other clients getting on and off at the bus stop there and em, yeah just people with money, people saying they were going to Cork … (Migrant Support Services)

Findings from our study show that service providers’ concern around female service users’ involvement in sex work are in line with wider research on sex work in Ireland (FitzGerald and McGarry, 2016; Huschke and Ward, 2017). The literature suggests that sex workers in Ireland consists of Irish and foreign nationals, who engage in underground activity, and are travelling around the country based on demand for sex services (Kelleher and O’Connor, 2009; Ward, 2010). While not knowingly working with sex workers, health and social care service providers believe that their service users are at risk of, or directly involved in sex work. It is, however, concerning, that service providers were reluctant to say openly that they have worked with sex workers, or that service users were reluctant to disclose to service providers their involvement in sex work, although, given the legislative landscape, this is also understandable.

Whether knowingly or unknowingly, service providers identified the risk to sex workers due to social exclusion. Women that do not have a fixed abode and not allowed to work may find themselves engaging in illegal activities simply in order to survive and provide for other family members. Sex work is one example for the impact that social exclusion and marginalisation has on the life of vulnerable populations (Benoit et al., 2018) and this provides the foundation for a strong argument for social inclusion policies that are inclusive of all regardless of nationality and circumstances. While social inclusion exists in Ireland (Benoit et al., 2018), barriers still exist. The next section will discuss the barriers that sex workers experience, as perceived by service providers.

Identified barriers to health services from service providers perspective

Where the above section explored service providers’ lack of knowledge of service user’s involvement in sex work, service providers also discussed the barriers experienced by sex workers in accessing health services, such as marginalisation; isolation, and capacity. ‘ … I see a huge need, a huge need for services … Yeah, yeah, I do. Because I think they seem to be very, very isolated and I think in isolation I think there’s a lot of danger’ (Sexual Health Service).

Service providers stated that ‘isolation is a barrier to both accessing health services and attaining support. In order to overcome such isolation sex workers’ participation in the development of services they need and will use could reduce the experience of isolation for sex workers and remove the sense of stigma, I would like to learn from the women themselves, what do they need and who are they?’ (Sexual Health Service). This would imply that the creation and distribution of health services must be both inclusive of sex workers’ health needs and create opportunity for them to participate in developing those services.

The service providers spoke about the experiences of undocumented women living in Ireland illegally. They identified that these women have precarious legal status because they are on student visas, holiday visas or are undocumented migrants (Ward, 2010). In Ireland’s domestic legal regime, undocumented, migrant sex workers have no right to access health services and risk deportation if identified by the authorities, ‘No one would, disclose to me … ’ (Migrant Services). Ireland’s legislation does not legislate for or include provisions for foreign nationals (Huschke and Ward, 2017). The impact of this was described by one service provider:

I would know of it happening … a few people disappearing, I don’t know how they’re supporting themselves. I had a case recently of a woman who, disappeared for some time, became pregnant and is now, kind of resurfaces to try and access medical support and is terrified! (Migrant Support Services)

The participant indicated that if a person finds themselves homeless with no address, then, they cannot access social welfare payments and financial support in Ireland. One service provider identified a service user that was involved in sex work while experiencing homelessness: ‘Em I’m just thinking maybe of a service user we would have had. Em, you know a few years ago, and she did have a history of prostitution [sex work], she would have talked about it … ’ (Homeless services).

A further barrier service provider discussed was that they did not feel equipped to address the needs of women involved in sex work within their service provision. ‘ … It would be very beneficial to be able have information here available generally for people around other supports … specific to prostitution’ (Sexual Health Service). Based on their experience with women, service providers felt strongly that stigma associated with prostitution serve as barriers to access existing services. This situation makes a strong case for better services locally and throughout the country for women involved in sex work. Where the Women’s Health Project has capacity to support sex workers who can access their service, this service could be extended throughout the country of Ireland. Service providers argued for tailored services specific for sex workers similar to recommendations made by international researchers (Howard, 2018; Platt et al., 2011; Sanders and Campbell, 2007), ‘The experiences of sex workers are unique, and services should be adapted to their multifaceted needs?’ (Homeless service). They are aware of the multifaceted needs of women in sex work, but they feel restricted in the care they can offer to them because of women’s complex needs. For example, the practical needs of women experiencing homelessness could be supported by homeless services. However, outside of their basic practical needs of emergency shelter, the service provider’s ability to move forward with long-term plans for the women was complex: ‘[E]m within the hospital it’s strictly a medical model so in order to access counselling … or supporting mental health through the hospital you must have a diagnosable psychiatric illness’ (Homeless services).

It is clear from our research that health and social care providers cannot, and do not, have the capacity to provide a service for women involved in sex work. However, their recommendations included budgetary measures to develop services, and education and training to providers in order to provide sex workers with supports. The development of capacity in health services for sex workers implies they should be of good quality and acceptable to the service users and address their specific needs (UN General Comment 14). Human rights norms propose that the right to health is respected, protected and fulfilled, which would entail providing services to those who are excluded from accessing them, in this instance sex workers. Therefore, in theory, services should extend to sex workers and involve their needs being respected, and specific services addressed to them being protected and fulfilled through their inclusion in health services.

Along with limited knowledge and experience about sex work in Ireland, health and social care providers felt ill-equipped to address the needs of sex work service users. Health care professionals tend to focus on the presenting complaint, possibly missing other indicators and deliver healthcare without tailoring their service needs to this group (Dahlgren and Whitehead, 2007).

… for someone say attending the STI clinic up at the hospital, it’s not ideal by any means how people have to attend that clinic … It’s an open door and you know em the opening hours aren’t flexible, it’s very limited, em, any woman, I think needing to attend that clinic there’s gonna be some anxiety or hesitancy around it. (Sexual Health Service)

In support of sex workers accessing services, the service providers wished to advocate for local services to provide information and support to women involved in sex work. They saw this as a gap in providing a service to the women: ‘ … It would be very beneficial to be able have information here available generally for people around other supports … specific to prostitution’ (Sexual health).

In this section, our research has shown that there are many barriers at local level for sex workers seeking to access a range of health supports. Yet these barriers do not exist in isolation, but rather because of what is occurring at a macro level, as social and cultural norms within a society are shaped by political ideology which shapes current discourse (Weeks, 2017). For this reason, sex workers barriers to health services must also be explored at a macro level. The following section considers legislative and policy barriers to providing health services.

Legislative and policy barriers to providing supportive services

While the previous section discussed barriers at the level of service providers, this section will discuss the barriers at a macro level, examining the role of social policies and legislation which frame service provision. Where previous findings have identified marginalisation (Phillips et al., 2012; Sanders, 2013; Sanders and Campbell, 2007) and isolation for sex workers as barriers to accessing health services (Sanders, 2013), current policies such as the National Sexual Health Strategy (2015–2020) and the Criminal Law (Sexual Offences) Act 2017 do little to address these barriers, but rather perpetuate the stigma and social malaise of sex workers (Weitzer, 2010). As one service provider stated: ‘[Things] … policies and the legislation would have to change, it doesn’t work with us to provide appropriate supports … ’ (Migrant Services).

At the level of the National Sexual Health Strategy, there is an aspiration to ‘promote a mature, non-judgemental attitude to sexual health and to remove stigma associated with sexual health issues in the provision of education, information and services’ (Department of Health, 2015: 3). Yet, in the same document, sex workers remain categorised as ‘at risk and vulnerable’ and are not consulted as agents able to speak to their own experience or identify their own service needs. Therefore, this policy document remains a barrier for access to services for sex workers, and the capacity for service providers to provide an appropriate service.

Legislation is also a barrier. Health and social care services identified that pre-2017, legislation hindered how service providers could support sex workers. Given their legal precarity, service providers added that women would not disclose their involvement in sex work to practitioners: ‘ … No one would, disclose to me … Why would they? They are working outside of the law and we cannot support illegal activity … ’ (Homeless services).

In Ireland, the situation for migrant sex workers is complicated by a number of issues. For example, those who do not meet the Habitual Residency Condition (criterion is living in the country for two years minimum to avail of social welfare services) are ineligible for social welfare. Current social welfare policy has been designed to limit immigrant access to welfare in response to a surge in the numbers of immigrants receiving welfare benefits pre-2008 (Barret et al., 2013). These circumstances leave migrant and foreign-born women who are not citizens of other European Union Member States at risk and marginalised. This becomes stark when and if they experience financial hardship, circumstances that may lead to them taking up sex work (Agustin, 2007). Moreover, Ireland’s Direct Provision asylum system imposes systematic poverty on asylum seekers. In short, by law, asylum seekers living in Irish reception or accommodation centres are not allowed to take up employment (at the time of the study) and are given a weekly allowance of €38.80 for adults and €29.80 for children (Barret et al., 2013). Because of the Refugee Act, 1996, service providers felt the women were vulnerable to those organising sex work. Therefore, Asylum-seeking women are less likely to have confided in anyone as they fear deportation. ‘ … [A]nd then even if we highly suspect or may have heard of a particular woman’s involvement, they are not going to tell us, or draw attention to themselves? The double edge sword of the law, prostitution and their application to remain in the country?’ (Migrant Supports Services).

Moreover, in the current shift towards decriminalisation legislation for the sellers of sex (Criminal Law (Sexual Offences) Act, 2017; Criminal Law (Sexual Offences) Bill, 2015), health services have remained excluded from prostitution discourse to date (Sanders et al., 2009). Government policies (Department of Justice and Equality, 2012; Joint Committee on Justice, Defence and Equality Debate, 2013) to address sex work have tended to focus on the law, the criminal justice system and punitive measures to tackle and reduce sex work activities at the expense of health and safety (Cusick and Berney, 2005; Hubbard et al., 2008). This approach has been criticised for its failure to adequately address sex work health needs and health and social care service development, which includes the wider social determinants of health. It is important to acknowledge foreign national sex workers also and how current legislation does not protect or provide for migrant, indoor sex workers (Huschke and Ward, 2017). As a service provider working in the migrant services sector acknowledged: ‘I know of many women that in dangerous situations have not availed of health support and have put their lives at risk, their fear of being identified … . this concerns me greatly’ (Sexual Health Services).

In contrast to the approach of current policy and legislation, a social justice lens requires that the development of future services is available, acceptable, accessible and good quality to sex workers. Commitment to social justice in policy and legislation is required to remove the barriers and address the needs of sex workers and access to health. Fitzgerald and McGarry view that ‘the idea that everyone deserves parity in terms of opportunities, political rights and distribution of wealth and privilege to participate as peers in social life and lead fulfilling lives’ (2018: xv) is useful in contributing to a more rigorous evaluation of the current condition of health services provision for sex workers in Ireland, in the context of legal and social policy provisions in Ireland (FitzGerald and McGarry, 2018). Services in Ireland currently are configured to address sex workers who are trafficked or who wish to exit sex work but does not reflect the current findings of our research. Through the recognition of sex workers as agents in the development of services, their status shifts from a marginalised group who are exclusively viewed as at risk and vulnerable, to one of being given parity of participation. To achieve this in Ireland, a paradigm shift in the delivery of health care is required. This will require a national review of existing health and social care services with a view to providing better, non-judgemental services for women in the sex industry, while re-considering the new legislation of 2017.

Conclusion and discussion

This paper contributes to the literature on discourses of social justice, health and sex workers. In the context of this study, we apply a social justice approach to capture how health services can integrate sex workers into their service provisions. To date, sex workers remain excluded from health services despite new legislation and the leading sexual health policy document (Department of Health, 2015). The study confirms that current policy and legislation are barriers to sex workers accessing health, unless they are deemed ‘vulnerable, or at risk’, trafficked or exiting sex work. Service providers in the study provide evidence that identifies these legislative and policy barriers and the consequences of these barriers at a local level, where despite acknowledging that their population groups continue to be involved in sex work, services neither have the capacity nor the skills to provide healthcare to sex workers.

Health and social care providers cannot, and do not, have the capacity to provide a service for women involved in sex work. However, their recommendations included budgetary measures to develop services, and education and training to provide sex workers with supports. The development of, and increased capacity in health services for sex workers implies they should be of good quality and acceptable to the service users and address their specific needs (UN General Comment 14). Human rights norms propose that the right to health is respected, protected and fulfilled, which would entail providing services to those who are excluded from accessing them, in this instance sex workers. Therefore, in theory, services should extend to sex workers and involve their needs being respected, and specific services addressed to them being protected and fulfilled through their inclusion in health services. This will require a national review of existing health and social care services.

What may be required, therefore, is a paradigm shift that takes up the social justice-based concerns outlined in our research. The findings indicate that the lived experience of sex workers, and service providers, require a step change in how the issue of sex work is addressed in the health services in Ireland. Currently, there are gaps in services provision for sex workers, which fail to acknowledge sex working women (Ward and Wylie, 2010). The problem of lack of recognition for this demographic has serious implications for Ireland’s ability to meet all members of society’s health needs and thereby as mentioned, challenges the efficacy of the National Sexual Health Strategy (2015–2020). A revised framework, to include and meet the needs of sex workers, would be one that is rooted a recognition of sex workers’ personhood and upholds their human right to health (WHO, 2015). A revised health paradigm based on the principles of social justice would place sex workers at the centre of all initiatives (Sanders et al., 2009). This social justice paradigm recognises sex workers’ autonomy and ability to make choices about their health and not categorise them as universally vulnerable or at risk but rather marginalised and isolated from health-related services in the community. This paradigm shift does not constitute sex workers as the ‘problem’ but rather takes the view that current health care provision promotes inequality among users and needs to be made more equitable. This paradigm shift in services would also give sex workers partnership in creating services that suit and respond to their needs. Participants’ independence and voice can shape the practical community-based distribution of resources and services, which implies the removal of barriers (O’Neill, 2013).

This paper concludes with advocating for the paradigm shift we are proposing, moving beyond the current framework that views sex workers as exclusively at risk and vulnerable, to afford them agency in the development of legislation and health policy. A social justice lens recognises the service providers concerns that there remain barriers to the provision of access, and a concern that services have gaps in their engagement with sex workers.

The results point to several specific areas where interventions could improve sex workers availability and access to services. The social justice approach identified in this paper has the capacity to improve the health and well-being for sex workers and other minority groups in society. A national review of existing health and social care services is a good enough place to start, within the complex context created, in part, by the Sex Offences Act of 2017.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Leigh-Ann Sweeney

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