Archive for August 12th, 2013

So far, all of my guest columnists have been female; this month I have the pleasure of presenting my first male guest columnist (other than my husband).  Kevin is a graduate student in epidemiology at Dalhousie University in Nova Scotia; he’s also a professional research consultant, which means he gets paid to help people design and conduct their research.  I thought you might enjoy reading what an actual scientist had to say about the state of sex work research.

I first came across The Honest Courtesan a little over a year ago after Maggie’s stint as guest-blogger for Radley Balko.  Some of the first columns that grabbed my attention were on the topics of bogus research on sex work and baseless numbers feeding malicious public policy, for obvious reasons.  Initially I was unconvinced that the field of sex work research was as bad as all that; “Surely, these are just a few hand-picked, exceptionally bad examples”, I thought.  I did a review of studies completed to date here in Canada, which has since branched out to the international literature as well.  To my surprise, Maggie’s characterization was spot on; studies on sex work often suffered from major flaws that made it hard to take their findings seriously.  This was even more surprising considering the fact that research on sex work was no new field; it’s been going on for decades.

hierarchy of evidenceResearch on a topic rarely starts with expansive, large-scale studies that answer all of our questions on a subject in a single salvo; in young fields, small-scale, low-cost studies help bridge the gap between idle guessing and establishing the first facts about an under-investigated topic.  As time goes on, the facts generated from such research are used to develop new hypotheses, which are then tested with more elaborate and rigorous methods.  What starts with case studies or focus groups eventually develops into large-scale cross-sectional surveys to accurately portray the population, cohort studies that follow participants for years at a time to establish cause and effect relationships, and eventually systematic reviews and meta-analyses that objectively review what is known about a given topic.  As a field adopts increasingly rigorous methods, we can have greater confidence in what we know about the subject.  Unfortunately, research on sex work has shown a staggeringly slow progression up this hierarchy of evidence.

One of the first things I noticed when surveying the literature on sex work was the overwhelming number of opinion pieces and editorials, which normally make up a tiny portion of articles published in academic journals.  In comparison, authors can routinely be observed arguing for shades of decriminalization and prohibition of sex work in the pages normally reserved for such tedious things as methodological advances and results from new studies.  The politics of sex work intrude into the realm of science to an astonishing degree, and I think this is one of the two main causes of the slow rate of advancement in sex work research.  As Maggie has pointed out more times than I can count, one side of the debate on the legality of sex work has a vested interest in portraying workers (and clients) as inherently dysfunctional; mass-producing hatchet jobs draped in academic garb is simply a means to that end.  Many such “studies”  are so poorly designed that anyone picked off the street at random could pull them apart in minutes; they’re a slightly more elaborate version of asking someone whether they’ve stopped beating their wife.  The end result is that the academic literature is a minefield of guesswork and kabuki dance posing as, and hidden amongst, earnest attempts to better understand the industry and the people in it.

Aside from the counter-productive dishonesty in the field, the other major limiting factor on the quality of sex work research is that it is really and truly hard to do.  The criminalization of sex work in many jurisdictions around the world makes recruiting large numbers of sex workers extremely difficult.  Likewise, the social stigma, potential for police to seek workers’ confidential data, and the risk of encountering an unethical quack all likely act to chill sex workers’ willingness to trust researchers enough to participate in studies.

The difficulty in recruiting for studies limits the options of honest investigators.  Here in Canada, sex work studies with fewer than 100 participants are par for the course; even recruiting fewer than 50 was relatively common less than a decade ago.  This is important because the size of a study’s sample determines how precise the estimates the study generates can be;out of focus the more participants an analysis includes, the smaller the margin of error for the results.  To put it another way, investigating a population with small samples is like looking at something out of focus; you’re sure something is there, and may even be able to make some educated guesses about what you’re seeing, but the fine details elude you.

Worse still, samples are almost always made up primarily or entirely of street-based “survival” sex workers recruited from addiction rehabilitation programs, which are used as convenient points of contact by researchers.  This method means that what is known of the industry is heavily biased towards the most visible and most marginalized segment of the market; the segment where rates of violence, substance abuse, and early age of entry tend to be highest.  The low-profile indoor market, which is generally estimated to make up ≈85% of workers (though we have no hard data with which to confirm this in Canada), is vastly under-represented in the literature.  Even when indoor workers are included in studies, the sampling hasn’t been designed to represent the sex worker population as a whole, meaning that even our most detailed picture of the industry is blurry and incomplete.

Despite everything you’ve just read I’m still optimistic about the future of the field for two reasons.  The first is that the composition of the people doing the research has changed a lot in the last thirty years.  While the appearance of HIV/AIDS was a huge political setback for the sex workers’ rights movement, it does appear to have attracted a new group of researchers, and much more rigorous methods, to the fray.  My review of the literature leads me to believe that, prior to the 1990s, most work done in the field was in disciplines such as Sociology, Criminology, Political Science and even the dreaded Women’s Studies; terms like feminism and patriarchy can be seen in actual, straight-faced research papers.  Epidemiologists and public health researchers began entering the field at some point after that, often tackling sex work research by investigating sexually transmitted infections, addictions issues, and the effect of public policy on workers’ health and safety.  Instead of engaging the topic from a political perspective, most modern sex work studies have adopted the dry, technical language and emphasis on coherent, replicable methods that one might expect from proper research.  Harm reduction has long-replaced feminism as the dominant framework seen in the literature.  The changes haven’t merely been superficial; whereas the studies of thirty years ago recruited <50 participants in one-off focus groups, some modern studies track over 500 sex workers for years at a time.  In countries where HIV/AIDS is more endemic (e.g., India), studies recruit workers by the thousand.  In short, researchers in the field of sex work are now putting in the hard work needed to get serious, credible answers to the most basic questions in the field; this isn’t the only recent change, though.

scienceinprogressThe second cause for optimism is the ongoing development and adoption of methods that enable researchers to circumvent some of the barriers to large-scale and representative recruiting of workers for studies, and for the first time put sex work research on par, quality-wise, with other fields.  Even the hardest-to-reach participants in the industry (e.g., underage workers) can now be efficiently recruited into large, representative samples that allow for accurate estimates of population size and structure; for the first time, we can credibly answer basic questions such as ‘How many sex workers are there?’‘How many work indoors versus outdoors?’, and ‘How many enter the trade underage?’.

It’s probably fair to say that, historically, the sex workers’ rights movement and the academic study of the industry haven’t had a good relationship; much of the time the field has seemed to be implicitly working for the other team.  Nevertheless, as the objectivity and quality of research improves, and as we learn more about the industry as a whole, fabricating “facts” about sex work becomes less and less effective a tool for pushing dangerous, wrong-headed policies.  As was the case when Canada’s sex work laws were tested in the Supreme Court earlier this year, the ability to decisively cut-down prohibitionist myths in real-time and in front of a panel of judges can be a powerful tool in fighting for sex workers’ rights.

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