Over this 9-year community-based cohort study involving 925 women sex workers, over half of participants (57.3%) saw mostly regular clients at some point. Those who saw mostly pre-screened regulars had reduced odds of facing workplace sexual violence and client condom refusal, highlighting how sex workers’ active screening and vetting of clients shapes clients’ behaviour and enhances sex workers’ safety and labour conditions within a criminalized context. The identified protective effect of seeing mostly regulars on sexual violence and condom refusal from our additive interaction sub-analysis was most significant among sex workers working in outdoor/informal indoor spaces. Under end-demand laws, participants had a 1.6-fold increased odds of seeing mostly pre-screened regulars (not fewer clients, but a greater proportion of pre-screened clients vs. new clients). Our findings suggest that seeing pre-screened, vetted regulars represents an important occupational health and safety strategy for sex workers which is rendered even more critical amid end-demand criminalization which has been documented to undermine sex workers’ ability to screen new clients(29, 32, 38, 44), and one which may be particularly salient in precarious work environments lacking the structural supports associated with formal indoor venues.
Seeing mostly regulars and diverse modes of work
In our study, sex workers who were older and worked primarily in informal indoor spaces (e.g., apartments, vs. on the street/in public) had greater odds of seeing pre-screened regulars, while non-injection drug users and those who faced recent homelessness had lower odds of seeing regulars, highlighting important class differences in sex workers’ ability to see regular clients. While over half of participants saw mostly regulars at some point during the study, 42.7% reported never seeing mostly regulars, highlighting a diversity of modes of sex work. 30.8% of participants worked in formal indoor venues (e.g., massage parlours) at baseline and had reduced odds of seeing mostly regulars, which is expected as many massage parlours are street-facing venues that receive one-time and walk-in clients. Formal indoor venues can provide an established clientele (i.e., clients who routinely visit the venue, negating the need for the worker to market their services/find their own clients) and managerial support with client screening(5, 37, 45–48) which can be particularly desirable for im/migrant women for whom language barriers and limited social capital can present challenges to independent sex work(49, 50). Further, prior research has shown that some sex workers prefer short client interactions due to desire for anonymity and/or not wanting to engage in emotional labour, and thus organize their work accordingly (e.g., by offering time-limited sexual services in formal indoor venues)(20, 51), while others highlight romance, emotional connection and intimate conversation as services offered to clients, and thus structure their labour to enable longer-term client relationships(51). In general, our results highlight diverse approaches to client type and work environments, suggesting that policy efforts to promote sex workers’ safety and sexual health including HIV/STI prevention should dismantle all restrictions which undermine sex workers’ screening abilities, and enable sex workers to structure their labour and select clients according to their own preferences.
Impacts of seeing mostly regulars on client condom refusal and workplace sexual violence
Our study found that seeing mostly pre-screened regulars was associated with reduced odds of client condom refusal (coercion into any type of condomless sex) within a criminalized setting. Our findings differ in some ways from global literature: in Asia and sub-Saharan Africa, the client vs. intimate partner boundary has been documented to be more fluid, with implications for condom use. In the Dominican Republic(52), Madagascar(21), Uganda(53) Nepal(23) and Indonesia(22), repeat visits and greater relationship intimacy (i.e., viewing the client as more of a boyfriend) has been associated with lower condom use. However, our results align with research from western contexts where sex workers reported high rates of client condom use and minimal overlap between clients and non-paying partners. In Scotland, sex workers used condoms almost 100% of the time with clients and rarely with intimate partners(18), and a Canadian study found that 87.2% of sex workers and 90.4% of clients reported always using condoms in a sex work encounter relative to 40.1% and 8.6% always using condoms in romantic relationships, respectively(54). Given the potential for HIV/STI exposure associated with condomless sex with many partners, there is some evidence that ‘hobbyists’ or clients who see sex workers often are more likely to use condoms: a US study found that regular clients were more likely to be risk averse and use condoms than were new (i.e., first time or second time) sex work clients(55).
Sex workers who saw mostly pre-screened regulars also had lower odds of facing workplace sexual violence (sexual assault or rape while working). Despite prominent stereotypes positing sex buyers as violent, research suggests that male clients of sex workers generally reflect the broader population of men(56–58); and reject sexual entitlement and ideologies that provocative women are deserving of violence(59, 60). Our findings are consistent with evidence that sex worker-client interactions are diverse; can range from violent (in the case of aggressors posing as clients) to uneventful to mutually pleasurable(11, 59, 61) as in other relationships and sexual interactions; and critically, highlight sex workers’ agency in their work. Moving beyond traditional public health research and legislative approaches which conceptualize sex workers as passive victims facing risk of client-perpetrated violence and HIV/STIs, the association between seeing regulars and reduced odds of workplace sexual violence can also be understood as a result of client selection, screening, vetting and retention processes implemented by sex workers. Clients who are respectful of boundaries (i.e., services offered, condom use) are those able to be seen again and become regulars. Clients are typically re-vetted by sex workers at every visit, with workers actively filtering the characteristics of repeat clients, shaping decreased boundary violations (sexual violence, condom refusal) among pre-screened regulars relative to one-time clients as identified in our analyses. Applying this labour lens to sex workers’ occupational safety strategies enables vital acknowledgement of their expertise and active participation in shaping the organization of their labour and filtering their clients (similarly to other small business owners), which is rendered even more critical by end-demand criminalization which has been shown to undermine sex worker and client communications and screening(29, 31–33). The use of this labour lens also affirms sex workers’ extensive advocacy efforts to resist against reductive frames of passive victimization, towards enhancing their rights(12, 37, 62, 63).
Interactions between seeing mostly regulars and work environment on workplace sexual violence and client condom refusal
In additive interaction models, the protective effect of seeing mostly pre-screened regulars on workplace sexual violence and client condom refusal was most significant for participants working in outdoor/informal indoor spaces, suggesting that under criminalized conditions, sex workers may see pre-vetted regulars to enhance their occupational safety in more precarious workspaces. The reduced odds of sexual violence and condom refusal for participants who worked in formal indoor venues whether they saw mostly regulars or not is consistent with epidemiological and qualitative evidence that managed indoor settings often offer crucial workplace protections to sex workers(1, 15, 37). Occupational safety supports in formal indoor venues can include security cameras; sexual health resources (i.e., education/condoms/lubricants); and the presence of venue managers, security, receptionists, and other sex workers to screen clients and monitor the space(5, 11, 37, 46, 61, 64, 65). A Canadian study found working in managed indoor venues to be strongly associated with reduced HIV and STI prevalence and enhanced condom use among sex workers(66). Despite the criminalization of third parties under end-demand laws in Canada and elsewhere, screening clients, intervening in and de-escalating conflict, and removing violent aggressors have been cited as critical roles of managers/security in indoor venues, which contribute vital oversight within the work environment and enhance sex workers’ physical and psychological safety(5, 6, 37, 50, 67). As our previous research found that sex workers who saw mostly regulars had lower odds of accessing third party (i.e., venue manager, security) support(47), our findings suggest that ensuring that sex workers can engage third parties to assist in the labour of screening/vetting clients if they choose may enable sex workers to see more one-time clients. Our results and existing evidence suggest that working in formal indoor venues with security and screening supports may alleviate sex workers’ need to rely on regular, pre-vetted clients in order to work safely in criminalized conditions.
In a setting where sex work is policed and clients are criminalized, our results highlight protective effects of seeing mostly pre-screened regulars, underscoring a need for policies which enable sex workers to structure their labour according to their own preferences to ensure optimal occupational health. The ability to screen and see new clients is critical for many sex workers’ income security – as it is for other small business owners – and should not present health or safety risks. Our findings contribute to a body of evidence demonstrating that sexual violence and HIV/STI exposure in sex work interactions are not a result of clients being unilaterally predatory, but are shaped by broader structural determinants including criminalization, punitive policing, work environments(1, 2, 4, 30), and misogyny and racism which impact both clients’ and police’s interactions with sex workers(11, 49, 60, 62). Across diverse settings, client criminalization has been shown to create greater pressure to accept clients’ terms, undermine sex workers’ negotiating power for condom use, and heighten their vulnerability to workplace sexual violence(9, 29, 32), highlighting how the structural violence of denying labour rights and protections to sex workers enhances workplace violence and rights violations against them.
Our study identified increased odds of seeing mostly pre-screened, regular clients (as opposed to one-time clients) post-end demand law reforms. This likely reflects the reality that under exacerbated criminalization which renders client screening more difficult, more sex workers are choosing to see clients who are pre-vetted and pre-screened. This finding is consistent with emerging evidence from Europe and Canada showing that end-demand criminalization has undermined sex workers’ ability to screen new clients(29, 32, 38, 44), as clients are more hesitant to provide personal information(29, 31–33) and third parties are criminalized for assisting sex workers with screening(37). When Canada’s previous sex work laws were ruled unconstitutional in 2013, the Supreme Court of Canada determined that screening is one of the most significant ways that sex workers are able to protect themselves from potentially violent or undesirable clients(68). However, under end-demand legislation implemented in 2014, 25% of sex workers reported reduced ability to screen and negotiate with clients(38). In another study involving clients, clients explicitly cited only seeing sex workers they had seen before and giving the least screening information possible to un-vetted sex workers as strategies to avoid potential criminal charges(44). This evidence and our findings suggest that both sex workers and clients may be prioritizing seeing pre-vetted individuals that they have seen before to mitigate the harms introduced by end-demand laws. Rather than leaving sex workers solely responsible for alleviating the structural vulnerability engendered by criminalization, legislative efforts to enhance their safety should dismantle all restrictive policies (i.e., client and third party criminalization) so that sex workers may organize their labour to create optimal conditions for occupational health. The full decriminalization of sex work would remove existing structural barriers to client screening processes, facilitating this vetting for sex workers across diverse work environments (whether they prefer to see mostly regulars or new clients(69, 70)) and advancing sex workers’ labour and human rights.
Strengths and limitations
This study relies on observational data which cannot be used to infer causality; additionally, our analyses rely on self-reported data which may be subject to recall, social desirability, or misclassification biases. However, our frontline staff includes experiential (current/former sex workers) and community-based staff with deep experience in building rapport with participants across interview and outreach activities, which is likely to mitigate social desirability bias. A strength of this study is its nuanced focus on sex workers’ agency and expertise, moving beyond more risk-oriented framings of past research pertaining to sex work clients. This includes the use of interaction models to further scrutinize variations in the relationship between seeing regulars and sexual violence and condom refusal outcomes across diverse work environments, which was informed by community feedback on preliminary results. A limitation is that our additive interaction term used a binary variable for work environment (i.e., formal indoor venue vs. outdoor or informal indoor space). While there are critical differences between outdoor and informal indoor workspaces, we grouped these due to the complexity of an additive interaction term with six categories. Though we hypothesized primary differences would be among formal indoor sex workers, we may have limited power to detect these differences due to the relatively small number of formal indoor workers who saw mostly regulars, and the non-significance of these results should be interpreted with caution. Further research is recommended to explore potential differences in seeing regular clients among sex workers working in street-based and diverse informal indoor spaces, ranging from private apartments to clients’ places to supportive housing settings.