“A law alone does not remove stigma”

Why was this research necessary?
Lara Vesentini: “The research was launched following the reform of sexual criminal law in 2022. Since then, sex work in Belgium has been officially recognised as a profession. Before that, sex work was tolerated in practice but still technically illegal on paper. That created all sorts of problems: sex workers, for instance, could not apply for bank loans or hire an accountant. Without any official employment status, they also had no safety net if their income dropped.With the reform, the main aim was to improve the situation of sex workers. Through our research, we wanted to examine what this change means for their access to healthcare. That is precisely where many continue to experience stigma, discrimination and misunderstanding.”

What are the main healthcare needs of sex workers?
“Traditional issues such as sexually transmitted infections and contraception remain important. However, what stood out in our research were complaints such as headaches and back pain. These are, of course, linked to the nature of the work. Take an erotic masseuse, for example, who may spend long periods standing and carrying out repetitive movements.Mental health issues also emerged very strongly. The stigma surrounding sex work remains considerable. Sex workers often prefer to remain anonymous for fear of negative reactions. The double lives some lead, and the anxiety of being ‘found out’, create significant pressure and stress. Working conditions also play a role. They are not always particularly safe or hygienic, and sex workers sometimes have to deal with difficult clients, which further affects their wellbeing.”

What barriers do sex workers face in mainstream healthcare?
“Many sex workers do not find it easy to be open about their profession. They say that GPs – often the first point of contact in healthcare – sometimes react negatively or have little understanding of what their work actually involves. They also frequently encounter assumptions: doctors who do not believe they do the job voluntarily or who associate it with mental health problems. On top of that, there are practical barriers, such as long waiting times for blood test results.”

Has decriminalisation already had an impact on their access to healthcare?
“Not yet, at least for the time being. The interviews for this study took place in the summer of 2023, around a year after the law changed. That is too soon to draw major conclusions; change takes time. It remains important to familiarise healthcare professionals more thoroughly with the profession of sex work and to make clear that people can choose this job voluntarily. There is still work to be done in terms of awareness. I also wonder to what extent the average Belgian is actually aware of this decriminalisation. Even the sex workers we spoke to did not have a clear understanding of what the new law meant for them in practice. A legislative change on its own is not enough, of course. It needs to go hand in hand with targeted interventions that tackle stigma and discrimination. Society’s perception of sex work does not change overnight. That said, decriminalisation has already paved the way for a new labour law in 2024. This allows sex workers to work under official employment contracts, with rights such as sick leave, maternity leave, pensions and protection against dismissal if they refuse clients or certain sexual acts. A significant improvement.”

How important are sex worker organisations in providing healthcare?
“Extremely important. These organisations often work with people who have personal experience in sex work themselves. They therefore know that world well, are approachable and non-judgemental. They proactively reach out to sex workers, for example by carrying out blood tests or collecting urine samples, and they form an essential link within the healthcare system. For undocumented sex workers, they are even more important, because without access to a health insurance fund it becomes even harder to navigate mainstream healthcare services. But challenges remain. Psychological support, for instance, is not part of their services, while waiting times in mainstream healthcare also remain long. Because there are so many different organisations, it is not always clear to newcomers where they can turn for help. And although sex worker organisations place a strong emphasis on outreach, it can happen that someone is with a client at the time and therefore misses an information session or testing opportunity. I also see these organisations as an important bridge to mainstream healthcare. They can help healthcare professionals better understand how to support sex workers, creating a stronger interaction between the two.”

What could healthcare providers already be doing differently today?
“Approaching sex workers without prejudice or assumptions – that is where everything begins. Do not assume that someone has mental health problems or is not doing the work voluntarily. Of course, you may ask questions about that, but do not start from that assumption. It is also important to recognise how demanding the profession can be. Sex work can be mentally taxing, just like other high-pressure jobs. That certainly deserves attention.”

What surprised you most during this research?
“What has stayed with me most is just how great the sense of relief can be when sex workers do feel able to tell their doctor about their profession. Respondents described how this gave them an enormous feeling of liberation and empowerment. We mainly see that openness among sex workers who have been active in the sector for longer. For younger sex workers, it often remains difficult. But these positive stories are hopeful. It also makes me proud of Belgium. We are the first country in Europe to decriminalise sex work and adapt labour legislation accordingly. Stigma and discrimination certainly still exist, but they are often more subtle than in countries such as the United States. Yes, healthcare providers sometimes lack knowledge or ask the wrong questions, but their assumptions usually stem from a sense of concern rather than rejection. There is something encouraging in that as well.”

Which voices still need to be heard?
“In this research, we were only able to interview sex workers with Belgian nationality. The voices of undocumented people are missing, even though they are often in more difficult situations. They often cannot, or do not dare to, make use of mainstream healthcare services because they are uninsured. Our findings therefore probably present an overly optimistic picture of reality. The new legislation aims to limit abuse, but it may be less able to protect sex workers without residency papers. Their voices absolutely need to be included in future research.”

What makes this topic personally interesting to you?
“Sex workers remain a group in a vulnerable position that receives far too little attention. Sex work is often referred to as the world’s oldest profession, which shows just how significant it is. Many people rely on and benefit from it. I therefore believe it is only natural that sex workers should have the right to social protection and safe working conditions. Research can help strengthen the position of sex workers: what do they need, and how can we respond to those needs? By communicating openly about this subject, I also hope to further normalise sex work. Why should it not be a profession people can be proud of? I look forward to initiatives that allow sex workers to work officially within safe and professional structures. Who knows – perhaps I will set something up myself one day!”