van Ravenswaaij, H., Rojas, D., Sharjeel, M., Slaats, P., Andelic, P., Paric, M. Improving the health status of sex workers in Europe (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph-4680 P a g e 1 | 9 POLICY BRIEF Improving the health status of sex workers in Europe: a policy brief with recommendations Hilde van Ravenswaaij1, Daniela Rojas1, Muhammed Sharjeel1, Puck Slaats1, Petra Andelic1, Martina Paric1 1 Department of International Health, Faculty of Health, Medicine, and Life Sciences, Maastricht University, The Netherlands Corresponding author: Hilde van Ravenswaaij, hildevr@outlook.com, Couwenhoven 4215, 3703ED Zeist, the Netherlands. mailto:hildevr@outlook.com van Ravenswaaij, H., Rojas, D., Sharjeel, M., Slaats, P., Andelic, P., Paric, M. Improving the health status of sex workers in Europe (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph-4680 P a g e 2 | 9 Abstract Context: Although the United Nations and the European Union are set to improve life on earth through the Sustainable Development Goals (SDG) Framework, sex workers have not been in- cluded in this Framework, thereby further increasing various issues, which affect this group, such as discrimination, stigma, and poor mental- and physical health. The COVID-19 pandemic has exacerbated the already existing disadvantages of sex workers, highlighting the need for a system- atic change to sustainably improve the empowerment and health status of sex workers throughout the European Union. Policy Options: The aim of this policy brief is to propose recommendations, which can contribute to the sustainable improvement of the health status and empowerment of sex workers throughout the EU. Policy options include a bottom-up approach with use of community-based organizations and public-private partnerships, targeting inclusion of sex workers, the organization of workshops, and the distribution of toolkits. Recommendations: - Inclusion of sex workers in the SDG Framework; - Organization of community-based workshops by and for sex workers; - Distribution of culture-personalized toolkits by and to sex workers. Keywords: Sex workers; Health; Empowerment; Policy brief; European Union (EU) Acknowledgments: We thank Martina Paric, our senior advisor, and Kasia Czabanowska for heart-warming support. Authors’ contributions: All authors contributed equally to this work. Conflict of interest: None declared Source of funding: None declared van Ravenswaaij, H., Rojas, D., Sharjeel, M., Slaats, P., Andelic, P., Paric, M. Improving the health status of sex workers in Europe (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph-4680 P a g e 3 | 9 Introduction To improve all life on earth, the United Na- tions (UN) has developed seventeen Sustain- able Development Goals (SDGs) (United Na- tions, n.d.). Each one of them is targeted to- wards a specific area or focus, which are meant to transform the world and make it a better place (United Nations, n.d.). Even though all Member States of the European Union (EU) have signed up to commit to the achievement of the goals and priority setting of SDGs on the EU agenda, the SDGs itself seem to lack addressing the complexity of is- sues at hand. For example, it has been found that while there has been mentioning of women’s empowerment and employment, the SDG Framework fails to explicitly in- clude sex workers in the Agenda 2030 and in all SDGs associated (Ingulfsen & Koob, 2018). The exclusion of sex workers in the SDG Framework seems to reaffirm the exist- ing stigma and disempowerment of sex work- ers (Ingulfsen & Koob, 2018). One might wonder how to improve the health status of a group that is never mentioned. One of the barriers which hinders improvement in the health status of sex workers is the lack of ac- cess to (high-quality) healthcare for sex workers in a number of Member States of the EU (International Committee on the Rights of Sex Workers in Europe and Sex Workers’ Rights Advocacy Network, 2020). Another barrier regards migration and the legal rights of sex workers, as Brussa (2009) found that up to an average of 70% of sex workers in the EU are migrants. Due to the limitation of rights for migrants in some Member States of the EU, sex workers face difficulty in access- ing certain services such as HIV- and STIs screening or treatment. The access to healthcare services can even be increasingly complicated for migrant sex workers with an illegal status (Benoit et al., 2017). Context The improvement of health status of sex workers increased in importance and rele- vance due to the recent COVID-19 pandemic, as research has shown that the COVID-19 pandemic has had an unproportionally large impact on sex workers. Beyer et al. (2020) have termed COVID-19 and HIV as syndem- ics given that both have similar structural and social drivers such as poverty, racism, lack of access to healthcare, and increased occupa- tional exposure. The COVID-19 pandemic and its related country-specific measures, have further exacerbated the barriers and is- sues that sex workers had to face. For exam- ple, sex workers were frequently ineligible to receive specialized COVID-19 financial schemes provided by governments due to their unconventional labour agreements, ille- gality or lack of registration (Platt et al., 2020). Another barrier to health status im- provement of sex workers, which became in- creasingly apparent during the COVID-19 pandemic, is the limited amount of funding allocated by different independent and non- governmental organizations (NGOs) to im- prove the human rights situation of sex work- ers (the Red Umbrella Fund, Mama Cash, & the Open Society Foundations, 2014). This lead to the necessary development of self- help initiatives by sex workers, for instance sharing of accommodation, bills, food and other resources (International Committee on the Rights of Sex Workers in Europe and Sex Workers’ Rights Advocacy Network, 2020). The COVID-19 pandemic highlighted the need for systematic change to sustainably im- prove the empowerment and health status of sex workers throughout the EU. The aim of this policy brief is to propose recommenda- tions, which can contribute to the sustainable improvement of the health status and empow erment of sex workers throughout the EU. http://www.sexworkeurope.org/ http://www.sexworkeurope.org/ http://www.swannet.org/ http://www.swannet.org/ http://www.sexworkeurope.org/ http://www.sexworkeurope.org/ http://www.swannet.org/ http://www.swannet.org/ van Ravenswaaij, H., Rojas, D., Sharjeel, M., Slaats, P., Andelic, P., Paric, M. Improving the health status of sex workers in Europe (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph-4680 P a g e 4 | 9 This policy brief’s vision for change is to em- power sex workers in the EU through com- munity-based integrative approaches that im- prove their mental, physical and socio-eco- nomic health status. Policy Options Schram (2017) found the bottom-up ap- proach to be effective in solution develop- ment. In fact, community-based organiza- tions could play an essential role in develop- ing an inclusive and contextual policy re- sponse by collaborating with local, munici- pal, and national authorities (World Health Organization, 2013). Community participa- tion ensures recommended policy options to be effective, feasible and effectively engage migrant sex workers (Beyrer et al., 2015). Therefore, the focus of policy recommenda- tions calls for a sustainable role of commu- nity-based organizations and initiatives through sufficient funding and technical sup- port to overcome policy gaps. To provide the resources needed for recommended policies, public-private partnerships (PPPs) are en- couraged. Within PPPs, both parties invest in the project to contribute to a societal purpose. It is a promising strategy to provide accessi- ble services for sex workers, who are more attracted by partnership approaches (Kokku, Mahapatra, Tucker, Saggurti, & Prabhakar, 2014). Inclusion of sex workers in the SDG Frame- work First of all, the existing stigma and disem- powerment of sex workers could be reduced by directly including the group in the SDG Framework and support inclusion in the de- velopment of policies and agendas being set (Ingulfsen & Koob, 2018). Not only does in- clusion result in a more complete and broad policy or framework, it also increases the im- portance of the group or topic being included (Kickbusch, 2009). Community-based workshops To address empowerment and improve the health status of sex workers through a bot- tom-up approach, workshops by and for sex workers should be developed in collaboration with local sex worker’s organizations in available community spaces. The integrative approach can address physical health issues such as HIV and STDs, but also mental health issues, including psychosocial well-being, discrimination, and stigma (Mantsios et al., 2018). External experts, such as health pro- fessionals, could be encouraged to participate in workshops and to provide information on health and safety. Conscientization, solidar- ity, understanding and hope are essential in achieving empowerment (Freire, 1972). Thereby, an individual is influenced by social structure, while in turn the social structure is maintained by the individuals. As a result, community empowerment can influence sex workers to take action, which can positively affect the community and workshops to be sustainable (Mantsios et al., 2018; World Health Organization, 2005). Furthermore, ev- idence shows that community empowerment- based approaches are associated with reduc- tions in HIV and other STIs, as well as in- creased condom use (Kerrigan et al., 2015). For sex workers, a community is often re- ferred to as individuals who share similar so- cial ties and a physical space, as well as hav- ing an awareness of identity as a group (Shan- non et al., 2007). Hence, a safe space should be developed, where the sex workers can share their experiences, educate each other, support one another, develop a sense of be- longing, and reflect on their status in society. In addition, involving sex workers and other potential project partners in planning and ex- ecuting the workshops, will attract them to participate (World Health Organization, 2005; World Health Organization, 2009). Due to the lack of funding by governments van Ravenswaaij, H., Rojas, D., Sharjeel, M., Slaats, P., Andelic, P., Paric, M. Improving the health status of sex workers in Europe (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph-4680 P a g e 5 | 9 and organizations for sex workers this policy option could appeal to the sense of commu- nity service from these experts and ask them to volunteer their time and expertise (Moore et al., 2014). These peer-led workshops have been shown to be effective in Canada, South Africa and India (Benoit et al., 2017; Huschke, 2019). Finally, partnership will be sought with existing sex worker organiza- tions and facility centres to implement the workshops. Planning and evaluating needs can be collaborated with the sex workers, sex worker organizations and facility centres to achieve effective workshops regarding the needs in local regions. Stakeholders can be attracted due to participation being voluntary, sustainable peer-to-peer workshops, and evi- dence-based approaches (Kokku et al., 2014). Culture-personalized toolkit The third strategy this policy brief recom- mends is to implement a toolkit for the sex worker community. Firstly, the toolkit should consist of basic health-related needs, such as condoms, as well as self-testing kits for HIV and other STIs. Testing of HIV and STIs should be executed confidentially, with in- formed consent and with counselling if needed (Center for Advocacy on Stigma and Marginalization, 2008). The self-testing kits will solely present the results to the sex work- ers themselves, which prevents stigmatiza- tion by healthcare providers and accommo- dates privacy (Stevens, Vrana, Dlin, & Korte, 2018). Moreover, the burden on the health system is reduced, which is beneficial particularly during health crises such as COVID-19. Nonetheless, if test results ap- pear to be positive for related diseases, for ex- ample HIV, HPV or chlamydia, sex workers should be provided the option of voluntary counselling and treatment (Center for Advo- cacy on Stigma and Marginalization, 2008). The toolkit can potentially also be used to provide other relevant equipment and infor- mation to the sex worker community, for ex- ample hygienic supplies and guides (NSWP, 2020). The toolkit should entail information and guidelines provided in paper and a link to the digital form, applicable in the Member State. The information-sheet will be broad, involving information on healthcare access, health education, insurance, counselling and potentially information with regards to the community-based workshops. Since a large number of migrant sex workers from several nationalities exists, all available information and guidelines should be translated into sev- eral languages, to provide accessible infor- mation for all sex workers. In this case, sex workers themselves could be empowered to translate information for the information- sheet with their language skills, thereby con- tributing to affordable and sustainable change (World Health Organization, 2009). Before the toolkit is implemented, local circum- stances together with relevant stakeholders should be analysed, such as sex workers, lo- cal sex worker organizations and potential project partners. Then, the creation of the toolkit can be supported by experts involved in the workshops to fill the information gaps identified by the sex workers. The stakehold- ers could be united with help from larger sex worker organizations which are experienced in developing projects, such as SWAN and ICRSE. The toolkit can obtain resources through donations of supplies, such as con- doms, rather than funding. Finally, the toolkit can also include tools for evaluating imple- mented interventions, such as evaluation forms, feedback systems, and guidelines on standardization of outcomes (World Health Organization, 2005). Recommendations The following recommendations are pro- posed to improve the health status and em- powerment of sex workers in the EU: van Ravenswaaij, H., Rojas, D., Sharjeel, M., Slaats, P., Andelic, P., Paric, M. Improving the health status of sex workers in Europe (Policy brief). SEEJPH 2021, posted: 18 August 2021. DOI: 10.11576/seejph-4680 P a g e 6 | 9 ➢ Inclusion of sex workers in the SDG Framework and actively supporting inclusion of sex workers in related policies being developed and agendas being set. This inclusion could reduce the current existing stigma and disem- powerment of sex workers. ➢ Community-based workshops by and for sex workers where, in an af- fordable manner they educate and support each other to tackle health-re- lated issues, mental health challenges, and legal issues. These workshops should be developed by collaborating with local sex worker’s organizations and facility centres that provide avail- able community spaces. These work- shops can empower the workers in a safe environment. Such an integrative approach is voluntary, low-cost and sustainable while effective in ad- dressing a broad range of issues that affect sex workers. ➢ Toolkits consisting of multiple com- ponents, to be provided during the workshops. The first component is a package of supplies to provide re- sources to tackle health related issues, for instance, condoms and HIV self- tests. The second component is the distribution of multilingual (non-) health related information in paper form and a link to the same infor- mation stated digitally. Conclusions The COVID-19 pandemic exposed the lack of mental, physical, and socio-economic health status of sex workers throughout the EU. Already existing barriers to the improve- ment of health status of sex workers include the lack of inclusion in the SDG Framework and the limited funding available. The three recommendations are an attempt to show how a sustainable improvement in health status and empowerment of sex work- ers in the EU can be achieved during and after the COVID-19 pandemic. If implemented simultaneously, the recommendations are ex- pected to impact the overall health status of sex workers in the EU. References 1. 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