In 1993, at 14 years old and pregnant with her first child, Janell Johnson-Dash was placed in a foster home. Soon, she was in and out of care, alternately living in group homes and on the street. As a young teen, she became involved in sex work.
Johnson-Dash became an HIV peer educator because her older teenage friends were testing positive for the virus, she says. Johnson-Dash was once part of a group of about a dozen sex workers based in New York City’s West Village neighborhood. Today, only four of them are alive.
No longer a sex worker, Johnson-Dash, 38, conducts research about the sex trade and is currently a field interviewer and HIV tester for the New York City Department of Health and Mental Hygiene. Johnson-Dash, who is also a survivor of sex trafficking, considers herself a “lifelong social justice warrior.”
“The majority of the people who I worked the streets with who were active sex workers were socioeconomically oppressed,” Johnson-Dash says. “Some had criminal records, so they couldn’t get jobs; some had families who didn’t want them because they were queer; and some didn’t want to be a part of the shelter system, so they did sex work to pay for housing. We weren’t a part of regular society, so we had to do what we had to do to survive.”
More than two decades later, a question lingers in her mind: Why did she lose so many of her friends to the virus?
According to the HIV education organization Avert, sex workers’ risk of contracting HIV is, on average, 10 times greater than individuals in the general population. And a meta-analysis from The National Center for Biotechnology Information concluded: “Very few studies have documented the prevalence of HIV among female sex workers in the United States; however, the available evidence does suggest that HIV prevalence among this vulnerable population is high.”
Why, then, while both national and global HIV rates fall, does risk for sex workers remain high? The most recent of several possble reasons is FOSTA-SESTA, a law signed by President Donald Trump in April.
The law is named after the House bill “Allow States and Victims to Fight Online Sex Trafficking Act” (FOSTA) and the Senate bill “Stop Enabling Sex Traffickers Act” (SESTA). It’s aimed at fighting sex trafficking by reducing legal protections for online platforms. In short, the federal government wanted to stop sex trafficking by shutting down sites thought to be promoting it.
Since the law’s enactment, classified ad site Craigslist has eliminated its personals section and the similar website Backpage has shut down entirely (though a different law was used to justify its closure). Both forums allowed sex workers to promote their services, and many sex workers say the law does more harm than good.
“Trafficking is a subindustry of the sex industry; the sex industry is not sex trafficking,” Johnson-Dash says. “There’s no differentiation in the FOSTA-SESTA law. They push people out of their safe zones. They push people away from communities where they can connect with each other for protection. People are back on the streets.”
Johnson-Dash says she remembers the sex trade of 15 years ago, before the internet came into play. It was ugly, she says.
“There’s a different type of client that logs onto the internet to find a sex worker versus someone that’s driving around in a car with $40 above his visor. They’re totally different kinds of clients. The risk is so high,” Johnson-Dash says.
Toni Newman knows these risks. She’s a former sex worker in New York City and the executive director of St. James Infirmary, a peer-based occupational health and safety clinic for sex workers and their families in San Francisco. On the street, she says, safer sex can be harder to negotiate, especially for transgender women of color.
“When I was a street prostitute versus an escort working in my own apartment, I had more control in my own place,” says Newman. “I could decide what I wanted to do, whom I wanted to do it with. FOSTA-SESTA has pushed a lot of the sex workers who advertised on Backpage, Craigslist and other places back on the street.”
Competition is often stiffer on the street too, says Matthew Rose, the policy and advocacy manager at the National Minority AIDS Council (NMAC).
“HIV can kill you in decades,” says Rose. “Going hungry can kill you in a week. So the prioritization of the danger to your life is a lot different, and what you’re willing to take as an acceptable risk is also a lot different.”
Magali Lerman, a former sex worker, consultant with Reframe Health and Justice Consulting (RHJ), volunteer with the Safe Night Access Project Seattle and president of Sex Workers Outreach Project–USA (SWOP-USA), says she has recently noticed about five times more workers on the street in Seattle.
“People are doing riskier things, such as condomless anal sex,” says Lerman. “So we’re definitely trying to get pre-exposure prophylaxis [PrEP] out on the streets.”
Street work can also mean a sex worker has less time to determine whether an interaction will be safe, says Kate D’Adamo, another consultant at RHJ.
“There’s nothing inherent to street-based work that makes it any riskier,” says D’Adamo. “When engaging in street-based work, all of the things that make people vulnerable are heightened. You are more visible, so you’re more likely to experience violence.”
FOSTA-SESTA is just the latest complication for sex workers. The perception of the industry itself factors into HIV risk among sex workers.
“[Some people] don’t understand what sex work is—it’s survival work,” says Shareese C. Mone, an advocate and a former sex worker. “There is a misconception of what sex work is. A lot of people think, ‘Oh, they’re just nasty,’ not realizing that a whole community is surviving off sex work.”
The link between sex work and HIV has been forged by cultural and social phenomena, including racism, classism, sexism, socioeconomic disparity and—perhaps above all—the criminalization of the sex trade.
“When things are criminalized, there’s no choice but to—for your own protection and safety—go underground, because you’ll at least be able to escape the carceral state,” says Preston Mitchum, the international policy analyst at Advocates for Youth. “However, although you’re escaping the carceral state, there is a high likelihood of acquisition of things like HIV and other sexually transmitted infections [STIs].”
Criminalization of sex work also serves to shift power from the worker to the customer as well as from the worker to the police, rendering condom use and negotiation difficult and otherwise jeopardizing sex workers’ safety.
“You can certainly tell the police [if you’re threatened], but we also know through reports and testimonies from sex workers that police sometimes are some of the greatest harmers of sex workers. That’s what happens when you have an environment that criminalizes them,” says Mitchum.
A 2012 Human Rights Watch Report detailed the use of condoms as “evidence to support prostitution charges” in New York City, Los Angeles, Washington, DC, and San Francisco, though each city has since limited the use of condoms as evidence or clarified its laws to varying degrees.
“There is the direct policing of condoms and safer-sex supplies,” says D’Adamo of Reframe Health and Justice. “So when a sexual exchange is criminalized and officers are looking for evidence of that interaction, something like condoms-—-when you’re policing someone—very easily becomes a piece of evidence, which means it becomes criminalized to have that piece of evidence on you.”
Penelope Saunders, the coordinator of Best Practices Policy Project, a sex trade advocacy group, says police will often throw condoms on the ground and destroy them.
“Police can act with absolute impunity toward sex workers,” says Saunders. “Police rape them, police take their condoms, police put sex workers in dangerous situations.”
It’s the stigma of the work that prevents them from getting the care that they need.
But activists like burlesque artist Akynos, the founder of The Black Sex Worker Collective in New York City, say focusing on the risks of sex work alone can be equally damaging.
“Throwing street-based work under the bus,” Akynos says, became more commonplace after FOSTA-SESTA.
“When [sex workers] talk about how much more underground they’re going to have to go and how dangerous street-based work is, they’re agreeing with the anti-sex work narrative that sex work is inherently dangerous,” Akynos says.
With the internet came the power to vet clients—to screen them via a laptop. Some sex workers, Akynos says, have “fallen into victimhood.”
“Many indoor sex workers let the internet confuse them into thinking that they were in some kind of safe space to work where the government gave a goddamn about sex workers and our rights,” Akynos says. “They don’t.”
Saunders says street-based work isn’t inherently more dangerous than any other form of sex work—it’s the criminalization that makes it so risky. And criminalization follows sex workers well beyond the street.
“A lot of sex workers avoid going to the doctor because they can’t find doctors that they can be honest with about their health issues,” says Johnson-Dash.
Problems can range from unwanted social work intervention to misgendering.
“A lot of the cisgender women I know who try to get public health services end up really hating it because most of us identify as some form of LGBTQ,” recalls SWOP-USA’s Lerman, who identifies as homoromantic. She says this is the reason she stopped going to a PrEP (pre-exposure prophylaxis) clinic.
That’s why places that provide culturally sensitive care like the St. James Infirmary are vital. The clinic provides free care supported by donations, and it treats clients without judgment. Executive director Toni Newman says it’s the “first occupational health and safety clinic in the United States run by sex workers for sex workers.”
Most places aren’t as understanding, says Rose of NMAC.
“You can’t talk to your doctor about what you do, which means that, especially for women, we’re going to miss risk for you,” says Rose, “and not get you appropriate services.”
Not getting tested for HIV can reach deeper than a fear of doctors. Fear of testing sits precariously at the intersection of the criminalization of HIV and sex work.
“As to HIV criminalization being a way of targeting sex workers, that’s certainly the case in the states that have the enhancements—and that’s about a dozen states—where your status can be used as a standalone basis for increasing what would be a misdemeanor crime to a serious felony,” says Kate Boulton, a staff attorney at The Center for HIV Law and Policy.
Some states impose mandatory HIV testing and felony upgrades for sex workers who know they have HIV. Citing research from sources such as HIV Criminalization in California, a report issued by UCLA’s Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy, Boulton says laws like this disproportionately affect sex workers.
“The state is obtaining this information about you that it then has in its back pocket, and sex workers are hyper-targeted by the police, so people get arrested over and over and over again,” says Boulton.
Reframe Health and Justice’s D’Adamo says she’s heard some people say testing is the difference between a misdemeanor and a felony.
“You have to know your status before you can be charged with a felony upgrade, so if you don’t know, then they can’t charge you with a felony,” says D’Adamo.
A study of a pilot education program published in The Lancet suggests that the “best way to address HIV/AIDS concerns among sex workers is a peer-led project,” says Saunders of Best Practices Policy Project.
Johnson-Dash remembers counseling others with HIV prevention information gathered from workshops and trainings she attended at LGBT centers. She even wore condoms pinned to her clothes, but her efforts didn’t always pay off.
“I could remember talking to them saying, ‘How did you become HIV positive after all of this talking we’ve done? ‘Oh, well, he had an extra $100, and he said if I just would take the condom off, you know?’ And that’s like person after person after person,” says Johnson-Dash.
Sex work is a minefield of illegalities that the passage of FOSTA-SESTA has only served to compound.
Ending criminalization, says Lerman, would lead to several benefits, including safer ways to report violence. But would it improve health outcomes? Newman believes so.
“If we could legalize it, take away the stigma, the shame, the fear,” she says. “If all that is taken away, I believe, yes, we could get proper testing. People would be more apt to get tested, and I think health-wise it could be better.”
Johnson-Dash agrees. “It’s the stigma of the work that prevents them from getting the care that they need,” she says. “So if the stigma was removed and regulations were put over it, then the people who do provide services can keep themselves healthy to continue providing their services.”
Change may be on the horizon. A Washington, DC, council member recently introduced a bill to decriminalize sex work in the nation’s capital, and a National Sex Workers’ Summit in Los Angeles issued a manifesto in June calling for an end to the criminalization of sex work.
“It’s a package in criminalization of people’s lives. Changing just one law would not solve it all—it needs to be a very sustained local engagement with policy,” says Saunders.
According to a recent report in The Lancet, decriminalization could result in an almost 50 percent drop in HIV cases in the next decade—and, perhaps, could change the lives of those who do sex work.
“Through the grace of God, I did not get HIV,” says Johnson-Dash. “Maybe the reason was for me to keep delivering this prevention message.”
EDITOR’S NOTE: The images illustrating this feature are part of a new series of work by HIV-positive artist Ben Cuevas titled Reinserted. This artwork merges archival photographs of people taken by Annie Sprinkle with present-day photographs taken by Cuevas of various locations in Times Square that were once the sites of adult entertainment venues. The HIV status of the subjects in the photos is unknown.