Stakeholders' Perceptions Regarding the Impact of the Working Environment on the Occupational Safety, Health, and Well-Being of Street-Based Sex Workers in Brussels

1. Introduction

Street-based sex workers (SSWs) are among the most vulnerable populations within sex work, facing significant health risks and occupational safety issues [1,2]. Research shows a high burden of sexually transmitted infections (STIs) and blood-borne infections among sex workers (SWs) worldwide [3,4,5].

Female sex workers are thirty times more likely to live with HIV than other women of reproductive age, with a prevalence of 36%, alongside higher rates of chronic disease, sexual and reproductive health and rights issues as well as mental health challenges, such as distress, social isolation, PTSD, anxiety, depression, and self-harm, often worsened by substance use [4,5,6,7,8,9]. Violence, including gender-based violence, is pervasive, with sexual violence rates estimated between 14% and 54%, while many cases go unreported, perpetuating marginalization and endangerment [2,5,7,8,10].

In 1978, activist Carol Leigh introduced the term "sex worker" to describe consenting adults engaged in sexual services for pay, challenging negative perceptions - such as immorality and criminality - and legitimizing the work against notions of human trafficking [11,12,13]. According to Sullivan's perspective, sex work (SW) should be considered as a spectrum of experiences ranging from empowerment to oppression, involving diverse forms and genders, from non-physical displays to high-risk sexual encounters, including street-based work prevalent globally [11,14,15,16,17]. SW intersects with societal beliefs on gender relations, power dynamics, and morality, with narratives around SW ranging from victimization to public nuisance, including the perspective where individuals assert their right to use their bodies without facing penalization or criminalization [5,18,19]. Other individuals involved in this economic activity may not identify as sex workers at all [5]. These powerful discourses stem from diverse political and ideological perspectives, shaping varying state responses to sex work. Despite efforts to deter SW, it persists, shifting focus to promoting occupational safety, health, and well-being (OSHW) rather than SW prevention [18,20].

This study uses Olufemi’s definition of the working environment (WE) as the settings, situations, conditions and circumstances under which people work [21]. Work environments can significantly bolster well-being, health outcomes, resilience and life standards or, conversely, precipitate and exacerbate work-related injuries and illnesses, affecting physical and psychological health [22]. The International Labor Organization reports nearly three million formal-worker deaths annually due to work-related causes, with informal workers at higher risk due to low social coverage [23,24]. Despite being considered the oldest profession, sex workers face marginalization, stigma, and criminalization globally, fueling violence and discrimination [25]. This often neglects OSHW concerns affecting sex workers [18].

In June 2022, Belgium reformed its penal code, becoming the first European country to decriminalize SW, following New Zealand (2003) and parts of Australia [5,26,27,28].

Prior to decriminalization, the abolitionist system tolerated the sale and purchase of sexual services between consenting adults aged 18 and above [27,28]. Hiring someone formally under a contract of employment for the purpose of providing sexual services was prohibited and thus, to circumvent this prohibition, employment contracts were established by referring to other types of activities, such as hospitality and massage. The reform of the penal code brings significant changes regarding self-employed - including street-based sex workers - and employed SWs, granting them equal rights to other formal workers. This includes the ability to accrue social benefits and the cessation of penalization for third parties involved [29]. Though exercising caution due to sampling and methodological concerns, the prevalence of SWs is estimated to range between 25 000 and 30 000 in Belgium. Before the reform, SWs were considered by the Federal Public Service as one of the most vulnerable working groups in terms of social protection access, including work-related health protection [30]. Advocates argue decriminalization is crucial for safer working environments, enforcing human rights and promoting sex workers’ health, well-being and safety [4,6,27,31,32,33].

Studies highlight harmful factors in SWs' working environments, like criminalization, lack of control over earnings and organization, societal stigma, absence of safe spaces, competition among SWs, and instances of violence. These factors significantly impact their safety, vulnerability to HIV/STIs, ability to negotiate condom usage, and susceptibility to physical and mental health disorders [5,6,31,34,35,36,37,38,39,40]. Friendships among SWs offer economic benefits, access to crucial information on HIV/STIs and protective measures, including against violence [41]. Research shows that non-decriminalized frameworks lead to unsafe conditions and health risks, while decriminalization improves safety and cooperation with law enforcement. However, challenges persist, including high rates of violence, harassment, and PTSD [2,25,43,44]. There is a gap in understanding specific working-environment elements and their effects on SSWs' safety and health, especially in Belgium (Brussels).

Belgium's decriminalization law (DL) is seen as an integral aspect of the working environment, enhancing Belgium's potential to achieve several targets outlined in the sustainable development goals (SDGs) 2030 Agenda, including health, decent work, reduced inequalities, and justice (SDGs 3, 8, 10, 16) [45]. This study explores stakeholder perceptions of the working environment's impact on the occupational safety, health, and well-being of street-based sex workers in Brussels.

The aim of the present study is to explore stakeholders' perceptions regarding the impact of the working environment on the occupational safety, health, and well-being of street-based sex workers in Brussels. The aim is furthermore to allow policymakers, service providers, advocacy groups, and other stakeholders to draw insight that can inform them about the aspects within the working environment of street-based sex workers that need to be maintained, adapted, or eliminated to sustain progress towards these goals.

2. Materials and Methods

A qualitative methodology was selected to explore stakeholders' perspectives on how the working environment affects street-based sex workers' OSHW in Brussels, aiming to capture nuanced insights [46]. This choice leverages the possibility offered by qualitative research to facilitate a profound and nuanced understanding of lived experiences, utilizing a comprehensive approach to acknowledge the complex, subjective, multifaceted, and socially constructed nature of reality [47,48,49].

Seven participants were then recruited; purposive sampling was used to gather diverse experiences, representing variability within the study area [48]. Three initial stakeholders in Brussels acted as gatekeepers, leading to four additional recruitments through snowball sampling, where the initial participants aided in the identification of subsequent ones. This approach was used due to difficulties accessing stakeholders, who are few, often overwhelmed, and sometimes reluctant to be interviewed due to the political and emotional sensitivity of the topic.

During study design, defining inclusion and exclusion criteria for selecting stakeholders was crucial due to the sensitive nature of the topic, potential divergence in values as well as ethical considerations. Stakeholders were included if they had direct contact with street-based sex workers in Brussels, were familiar with the latter’s working environments, and were interested in their health and well-being. Exclusion criteria included a lack of understanding of street-sex workers’ OSHW needs, no direct contact with SSWs in Brussels, and conflicts of interest that could raise ethical concerns regarding the potential benefits of the research for street-based sex workers [48].

Maximum variation sampling ensured trustworthiness, involving selecting subjects who significantly differ from each other, thus identifying patterns across diverse groups [48].

Data were collected from seven interviews lasting 45-65 minutes, all conducted in French - one of the official local languages in Brussels, the native language of the interviewer and the language chosen by all participants - and recorded with two devices.

Data collection consisted of individual in-depth interviews employing a prepared semi-structured guide and a mind map to navigate topics and ensure all themes were covered [48]. Thematic structuring was employed during interviews, through open-ended questions. The interviews explored two focal themes: participants’ perceptions of street-based sex workers' working environments in Brussels and the impact of the working environment on street-based sex workers’ occupational safety, health, and well-being.

Inductive qualitative content analysis was used to identify variations and similarities within codes and categories, aiming to discern patterns, providing a structured framework for delineating explicit content and interpreting implicit content, while remaining closely linked to participants' lived experiences [48,51,52,53]. The goal is to progress from concrete data to a more abstract and theoretical understanding, revealing insights that enhance comprehension of the phenomenon studied, without introducing entirely new theoretical frameworks [51]. An example of the analytical process can be seen in Table 1.

Audio recordings were transcribed verbatim and translated into English before analysis. The text was decontextualized by selecting and condensing meaning units to preserve the core meaning, then labeled with descriptive codes aligned with the original text to minimize abstraction [52,53]. The coding process was repeated multiple times to ensure all meaning units were accounted for. This systematic approach was applied uniformly to all interviews, after which codes were grouped into content areas. The subsequent step involved re-contextualization, grouping codes by similarities to create sub-categories, which were then organized into categories. The underlying meanings of the categories were distilled and interpreted to form an overarching theme [52,53].

Adhering to the principles of qualitative content analysis, the methods involved describing manifest content as closely as possible to the text. Additionally, latent content was interpreted [51,53]. Textual analysis was conducted using a spreadsheet, and the entire process was outlined in a table to allow team review of analytical choices. Table 2 presents the study's key findings.

To uphold the ethical standards of the Helsinki Declaration a recruitment protocol was implemented. [54]. Before scheduling interviews, participants received a written information letter in French and English to ensure autonomy, a consent form, and verbal information were provided as well, allowing participants to confirm their interest and to ensure their understanding [46,48,55]. Participants were informed about the voluntary nature of participation, the study's aims, their role, the interview duration and method, their rights, contact detail as well as confidentiality measure such as the anonymization of data, including personal names, colleagues' names, specific locations, and workplace names. Each participant was assigned a unique ID for further confidentiality [46,48]. Both oral and written consent were obtained before interviews, with a consent form adapted from a WHO template [56]. Participants were given the opportunity to ask questions, and provided oral consent, which was recorded.

While participants were given the option to choose between online or physical interviews in Brussels, all were conducted online due to scheduling challenges and participant preferences. They were also warned about confidentiality risks, particularly when selecting their location choice, highlighting non-malevolence and harm prevention [46,48]. To ensure reciprocity, participants were offered to receive the final report via the recruitment communication channels to review the work before its completion, aligning with the principle of beneficence [47,48]. Participants were also given time to debrief after the interviews.

3. Results

Five of the participants were identified as males, and two as females, with ages ranging from twenty-eight to forty-two years. Their experience in their current positions varied from two to twenty-four years, with some having no prior experience with street-based sex workers. All participants had direct contact with SSWs, with six of them involved in both fieldwork and on-site activities, and one conducting interviews in working areas. Five participants were professionals, including a unionist and two social workers, one of whom also held a nursing position, an inspector of the vice squad, and a researcher. Additionally, two informants volunteered.

To address stakeholders' perceptions of the impact of the working environment on the occupational safety, health, and well-being of street-based sex workers in Brussels, information from all participants was included in the analysis and considered in the discussion of the results.

The data analysis an overarching theme: " A power imbalance and a lack of concerted efforts among stakeholders are detrimental to the occupational safety, health, and well-being of SSWs”. This theme was derived from 14 sub-categories, and then 3 categories: “Individual characteristics and contextual factors can result in both satisfactory and adverse OSHW outcomes”, “SSWs’ decreased agency regarding their working environment leads to poorer OSHW outcomes for them”, “Vested interests and political agendas significantly exacerbate harmful working environments (WEs) and contribute to adverse OSHW outcomes”.

3.1. Category 1: “Individual Characteristics and Contextual Factors Can Result in Both Satisfactory and Adverse OSHW Outcomes”

The first category was derived from 6 sub-categories: “There are as many profiles of SSWs as there are outcomes for their OSHW”, “Individuals from disadvantaged backgrounds experience the poorest WEs and OSHW outcomes”, “Perception of the overall impact of the working environment on SSWs’ OSHW”, “The slightest event can completely tip everything over”, “Societal protection influences both WEs and OSHW outcomes” “Positive and negative DL impacts”.

3.1.1. There Are as Many Profiles of SSWs as There are Outcomes for Their OSHW

Many of the stakeholders interviewed report the difficulty of making generalizations regarding the WE and occupational safety, health, and well-being outcome of street-based sex workers in Brussels, because there are as many profiles of SSWs as there are outcomes. Among street-based sex workers, some work for pimps, which complicate efforts to identify and address their needs. Others keep their activities hidden from family or engage in sex work temporarily and don’t identify as SSWs. Some advocate for their rights and form unions, while others feel coerced into SSW due to discrimination in other sectors or out of economic necessity. Additionally, Brussels has two main areas where grassroots organizations intervene: one in a neighborhood with socioeconomic issues and the other in a fancier area catering to a wealthier clientele, with sex workers mainly operating in standard hotels. Some aspire to leave SSW/SW, while others intend to continue. These diverse circumstances result in different working conditions and outcomes.

“Some don't have papers, no diplomas, don't want to be maids, so, it's the option that remains. Some are street-based sex workers but not in the political, militant thing of having chosen. They are very aware of the choices available to them. It's so, vast that even in a very small area, there are already such different profiles and types of SWs, ways of operating, ways of perceiving themselves completely different. It's not easy to make generalizations. The experience of a transgender person from Latin America or the experience of a cisgender person from Romania in the same space will be completely different. The relationship to work, the relationship to the client, the way of operating in space. You could do research solely on transgender people from X, for example. There are as many problems as there are profiles, people”.

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3.1.2. Individuals from Disadvantaged Backgrounds Experience the Poorest WEs and OSHW Outcomes

Individuals from disadvantaged backgrounds experience the poorest WEs and OSHW outcomes. The majority of undocumented SSWs in Brussels lack labor rights and face challenges such as limited language proficiency. They often come from impoverished backgrounds with limited education and literacy skills and experience repeated violence. Additionally, some face transgender stigmatization or mental health issues, leaving them with few economic alternatives and little awareness of their social and health rights. This often results in them resigning themselves to working in a harmful WE, leading to feelings of powerlessness. Enduring high levels of stress and trauma-related conditions can trigger or exacerbate mental health issues. In addition, gynecological problems, sleep disorders, broken limbs, chronic pain, hypervigilance, post-traumatic stress, breakdowns, substance abuse, and chronic health issues are among the most prevalent consequences.

“But there is always the confluence of origin, legal status in the territory, and also politics […] Regulations that work together have an effect on a person's health […]. It’s necessary for individuals forced to do SW to be able to exit that position as quickly as possible […]. However, unemployment benefits only come with an employment contract […]. The extent to which a person can choose their own working conditions always leads to better health because a person will always make choices that are in the interest of their health”.

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3.1.3. Perception of the Overall Impact of the Working Environment on SSWs’ OSHW

Regarding the impact of the working environment on street-based sex workers’ occupational safety, health, and well-being, stakeholders note financial pressures compounding challenges for SSWs. A decline in clientele fosters competition and risky practices such as unprotected sex for the same rate, leading to a surge in STIs, while maintaining precarious financial situations. Conflicts arising among street-based sex workers due to competition, along with fear during clients' negotiations, exacerbate stressful working environments and exclusion among SSWs, aggravated by inter-ethnic conflicts. Dwindling clients, low rates, and financial struggles drive SSWs to increase activity, resulting in fatigue, discouragement, lack of solidarity and adverse health effects.

“Competition among SWs is greater. To get clients, many accept risky practices: unprotected oral sex and unprotected intercourse. That undermines the whole system, everyone else. Because for the same price, they accept sex without a condom. There are often negotiations on the price, but it's mostly negotiations regarding practices. As a result, street-based sex workers who enforce the condom, lose the clients and the money. The risk in the long run is an alignment of practices and that they all end up accepting to do it without a condom, or other risky practices”.

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3.1.4. The Slightest Event Can Completely Tip Everything Over

Many of the stakeholders reports that the slightest of events can completely tip everything over. Random societal events, such as terrorist attacks, the COVID-19 pandemic, and inflation, have contributed to shaping harmful and unsafe working environments for SSWs. These unpredictable events have led them to face financial hardship, compelling some to work during the Covid crisis despite health concerns. Forced evacuations and limited access to essential medication for itinerant sex workers have further complicated their working conditions. Economic crises have triggered economic concerns for the most vulnerable, as they threaten the sustainability of SSW, exacerbated by scarcer clientele due to telework and rising living costs.

“All is fragile, the slightest event can completely tip everything over. During Covid we started making food parcels [even] for people who usually were comfortable”.

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3.1.5. Societal Protection Influences both WEs and OSHW Outcomes

Stakeholders note that street-based sex workers face numerous occupational safety, health, and well-being challenges, and that societal protection influences both working environments and OSHW outcomes. Belgium's universal healthcare coverage offers vital support. Special public funds during Covid have facilitated tailored a few social services in some areas, proving invaluable. Efforts to provide essential medications, like preventive HIV drugs, yield positive occupational safety, health, and well-being outcomes. The presence of the vice squad and their collaboration with grassroot NGOs, significantly impacts WEs, offering human contact, empathetic listening, protection from human trafficking and fostering a sense of security for many street-based sex workers. However, local legal support, labor laws, tailored healthcare OSHW services are lacking, further exacerbating OSHW issues, particularly for undocumented street-based sex workers, who have limited exit strategies and minimal access to comprehensive assistance. For many SSWs who lack economic alternatives, stakeholders report being able to provide only basic support.

“We’re not really concerned about their visa, unlike the uniforms. […] On the contrary, we try to help these girls. When we're there, they're happy. […]. We have work phones, they know they can call or leave me a message and I'll call them back, if they have a problem. […]. They feel more protected when we're there, for sure […] it's a very complicated neighborhood. Indeed, we need a district reserved for that. There’s no police station in the working areas because it's politics. They decide. We're just actors. We do what we can with what we have”

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3.1.6. Positive and Negative DL Impacts

Stakeholders recognize some benefits from the DL, such as decreased fear of local police (LP) intervention and increased legal awareness among SSWs. The law also allows for third-party support, provided it does not generate "abnormal income." However, challenges persist: many street-based sex workers cannot afford safety services, the law lacks a supportive legal framework for street-based sex workers’ occupational safety, health, and well-being, and implementation of labor laws are still to be implemented. Recent legislative changes are perceived to target formal sex work establishments, with little impact on SSWs and no consideration for undocumented individuals. Concerns arise regarding the vague definition of "abnormal" income for third parties, leaving gaps in legal protection for SSWs.

“Decriminalization aimed to remove the barriers that make it complicated. But it will stay complicated as long as there is no legal framework for work, and that the laws aren't passed. They can't declare their income from SW. The problem is that the risks of the job, the medical expenses, and everything related to SW, are not the same as if one were doing massages. An example is to know if pregnancy is a work accident or a medical risk related to work? We can't declare it if we are declared as a masseur. And it will only be for people who can work legally, who have papers. More than half of the people we see are undocumented and have little chance of obtaining papers. The situation won’t improve until we achieve radical progress on these issues”.

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3.2. Category 2: “SSWs’ Decreased Agency Regarding Their Working Environment Leads to Poorer OSHW Outcomes for Them”

The second category was derived from 4 sub-categories: “Impact of organizational strategies among SSWs aimed at enhancing work opportunities”, “OSHW outcomes stemming from interactions with clients”, “Positive impact of NGOs' outreach in WAs on OSHW”, “OSHW directly and indirectly adversely impacted by organized criminal network”.

3.2.1. Impact of Organizational Strategies Among SSWs Aimed at Enhancing Work Opportunities

Street-based sex workers employ organizational strategies to improve work opportunities and ensure occupational safety, health, and well-being. This includes selecting safer, well-known and working places offering facilities access to meet their clients. A remaining love hotel, in one of the main working areas, collaborates with grassroots organizations to facilitate access to medical services, lubricants, condoms, while offering essential amenities, and safety. Cafes and night shops serve as crucial social hubs, offering water, sanitation and hygiene (WASH) facilities, dining, shelter, seating, and security from street violence, facilitating interactions between street-based sex workers and clients. Despite these positive elements, vulnerable SSWs may resort to working in unsafe public spaces or cars, leading to poor safety and health, outcomes. Stakeholders note worsening conditions due to challenges in accessing essential facilities, leading to prolonged waiting hours, street insecurity, fatigue, and psychological distress among SSWs.

“Love hotels provide safety and hygiene […] Clients can be asked to wash up before the transaction. In the love hotels there are people coming and going and people managing it, which can be useful in case of trouble. They are not isolated”.

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3.2.2. OSHW Outcomes Stemming from Interactions with Clients

OSHW outcomes also stem from interactions with clients. While contentious among stakeholders, the concept of "good" and "bad" clients is acknowledged within the perception of some SSWs. Good clients are valued for their discretion, regularity, adherence to terms, and respectful behavior, fostering a sense of security and control. Conversely, interactions with “bad clients” are characterized by fear, harmful negotiations of price and practice, as well as instances of violence and a heightened level of stress and vulnerability.

“There are good clients, such as guys that you never spot because they are discreet. The guy that has a favorite girl, knows her schedule, and only goes to her. You'll barely see him passing through the love hotel because, he's a person who doesn't want to be noticed. These clients don't pose any problems. Then other groups of men [..] It's the kind of profile they reject, because they are not respectful, don’t pay, […] try to negotiate at the last minute for practices they hadn't agreed on initially”.

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3.2.3. Positive Impact of NGOs' Outreach in WAs on OSHW

Local NGOs play a pivotal role in providing tailored support and facilitating social and healthcare access for street-based sex workers, often serving as their primary resource. They engage in consistent outreach efforts across various working areas, offering on-site services. NGOs adopt holistic approaches, providing free distribution of harm reduction materials, STI screenings and treatments, as well as counseling, educational, psychosocial, and psychological support. They collaborate with each other and select state services to bridge gaps in access, addressing obstacles like language barriers and stigmatization. Despite some resource constraints, they earn praise and gratitude from SSWs for their invaluable assistance.

“We can see the benefits we bring. [..] we had contact with the Public Center for Social Actions responsible for providing social assistance to people, including medical cards for undocumented individuals. After multiple meetings with them, we agreed to have a specific social worker who could take care of all the SWs working in that municipality”.

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3.2.4. OSHW Directly and Indirectly Adversely Impacted by Organized Criminal Network

Street-based sex workers' occupational safety and health is significantly affected by organized criminal networks, as stakeholders emphasize. These networks and pimps exert control over SSWs, limiting their access to support services like NGOs and the vice squad. Some pimps only allow SSWs access to sexual and reproductive healthcare during NGO outreach, aligning with their business interests. Additionally, the management and distribution of key SSW areas restrict street-based sex workers ability to select safer work locations, increasing the risks they face. While some independent street-based sex workers appreciate their autonomy, those under exploitative conditions lack control over their working environment, enduring long hours with minimal breaks, an inability to leave work at will, and being deprived of their earnings.

“We encountered what we call "kettles" which are groups of 6 or 7 women surrounded by men. These are the pimps. In these situations, you can't approach the women directly because they are shielded by the men. We tried to get closer, but were immediately rebuffed. This situation went on for a while, we felt unsafe, and we were extremely worried about the women's safety. We had no contact with them”.

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3.3. Category 3: “Vested Interests and Political Agendas Significantly Exacerbate Harmful WEs and Contribute to Adverse OSHW Outcomes”3.2

The third category was derived from 4 sub-categories: “NC’s ideology and vested interest leads them to resort to violent and unscrupulous methods to make street-sex work disappear and create a harmful WE”, “Using unlawful regulations and LP harassment to serve the mayor’s ideology and vested interests is detrimental to SSWs”, "Crackdown on SSWs: implications and consequences of police actions and hidden work", “Implication of urban modifications for SSWs’ working environment and OSHW outcomes".

3.3.1. NC’s Ideology and Vested Interest Leads Them to Resort to Violent and Unscrupulous Methods to Make Street-Sex Work Disappear and Create a Harmful WE

Stakeholders report the presence of a neighborhood committee (NC) actively engaged in an aggressive anti-street sex work campaign, resorting to violent and unscrupulous methods to eradicate sex work and create a harmful working environment. Motivated by vested interests and misconceptions regarding neighborhood security, they employ tactics ranging from exaggerated accusations to harassment and violence against SSWs, including frequent police raids prompted by repeated calls, and pressure to close venues frequented by street-based sex workers. As a result, street-based sex workers suffer from mental health issues and deteriorated well-being exacerbated by pervasive stigmatization in their work environment.

“The ambition of the NC is ideological […] They throw eggs, shit and they spit on them […] That's also why one the mayor has closed several bars. The problem is that the residents don't see that street-based sex workers are like them, victims of violence”.

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3.3.2. Using Unlawful Regulations and LP Harassment to Serve the Mayor’s Ideology and Vested Interests is Detrimental to SSWs

The mayor's support for the NC has led to love hotels high taxation, the closure of cafes and love hotels in a key working area for street-based sex workers, causing fear among other establishments and prompting them to deny entry to SSWs to avoid closure. This action has deprived street sex workers of safe spaces for client meetings and negotiations, as well as essential amenities access. Stakeholders identify the mayor's political ambitions and vested interests, including ideological ideas and re-election, as significant obstacles to enforcing the sex work decriminalization law. Through unlawful municipal regulations, the local police are instructed to expel SSWs and their clients from the municipality, disregarding the decriminalization law. Any interaction with a sex worker may result in administrative sanctions without proof of a sex work context, deterring discreet and respectful clients from seeking sexual services and leading to reduced work opportunities and substantial economic losses for SSWs. Stakeholders express street-based sex workers' deep sense of abandonment due to the municipality's lack of political will to ensure a sound WE. The absence of these resources contributes to the deterioration of the overall working environment and occupational safety and health for SSWs, leading many to lose interests in pursuing SSW.

“The municipality says they are abolitionists and SW only means exploitation and human trafficking. The mayor, doesn’t want to allow that on his streets […]. It's accompanied by a phenomenon of chasing away clients. They say, if the clients stop coming, the SSWs will have to go elsewhere. The city of Brussels passed a police regulation that was unlawful. Clients were receiving administrative sanctions for soliciting. Based on the simple observation that a man is talking to a woman identified as a sex worker, he was subject to a municipal administrative sanction. […] There's really been a significant decrease in the number of workers who say it's not worth it anymore”.

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3.3.3. Crackdown on SSWs: Implications and Consequences of Police Actions and Hidden Work

Stakeholders report crackdowns on SSWs, with harassment and violence in their working areas from the LP. Strategies include repeated visa checks with the threat of deportation, aggressive behavior, especially towards transgender individuals. Additionally, the local police are described as unhelpful, often delaying or providing no response after SSWs are assaulted, preventing them from accessing protection and from enforcing their rights and making them vulnerable to victimization by fake clients aware of their lack of power. Consequently, street-based sex workers lack police protection, distrust local police, and often minimize their issues to avoid involving the LP, leading to enduring violence, and working in a highly stressful environment.

“They ask them to go work on an unsafe boulevard, much further from love hotels. SSW there isn’t safe […] so they hide, they wait for the police to leave and then they come back to the same spot. But it's experienced as systematic harassment against them. Trans people often face lots of transphobic behavior from the police. They feel harassed. They are subjected to body searches and asked to undress. But some don’t want to undress because they may not have undergone sex reassignment surgery. They wear wigs, so, asking a trans person to undress is horrible, it's experienced as a very traumatic thing. The police are not playing their role of protection even though it's a super vulnerable population. They are called in by complaining neighbors and they are in a mindset of cleaning up the public space”.

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3.3.4. Implication of Urban Modifications for SSWs’ Working Environment and OSHW Outcomes

Political agendas favoring gentrification or intentional efforts to displace street-based sex workers result in urban modifications and significant consequences for their working environment and occupational safety, health, and well-being outcomes. Law enforcement redirects SSWs to more unsafe areas, away from the love hotel and client-frequented zones, leading many to hide and remain invisible in their usual working areas. This creates an unsafe environment where SSWs are vulnerable to victimization and have less access to public health assistance and to the protection of the vice squad. Gentrification of the surrounding area displaces populations with deep social issues, concentrating them in the main working area and transforming it into one of Brussels' toughest neighborhoods. This fosters violent interactions and petty crime, shifting the vice squad’s focus from protecting street-based sex workers to preventing neighborhood violence. Measures to deter SSWs from working in this area, such as prohibiting cars, reduce foot traffic and increase violence against SSWs and client theft. The lack of police oversight deters clients from seeking sexual services and leads to stress and health issues for SSWs who endure violence daily. Attempts by street-based sex workers to relocate face obstacles due to municipality-employed urbanization strategies aimed at deterring SSWs from operating anywhere in the municipality.

“It comes from the organization of public spaces. They redid the square and removed all the benches. There's no way to sit down. They moved the French fry vendor to the very front of the square. They put in a fountain with water jets coming out of the ground. The intention behind this is really that the street-based sex workers don't stop there, that there's no longer a way for them to be visible, to be present. When you work five hours a night on ten-centimeter heels, there's really a desire to sit down”.

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4. Discussion

The aim of this study was to understand stakeholders' perceptions of the impact of the working environment on the occupational safety, health, and well-being among street-based sex workers, in Brussels. The analysis of the results from participant interviews found one overarching theme: “A power imbalance and a lack of concerted efforts among stakeholders are detrimental to the occupational safety, health, and well-being of SSWs”. While this research acknowledges the challenge of making sweeping generalizations, it resonates with the broader global population, as described by stakeholders.

Macro-structural determinants

Despite the decriminalization law of sex work and the beneficial existence of some support systems such as universal healthcare coverage, regular vice squad presence, and NGO outreach, comprehensive support remains challenging to provide, especially for marginalized and undocumented individuals, those facing financial hardship, individuals seeking to leave sex work, and those coerced or manipulated. External crises like the Covid-19 pandemic, terrorist attacks, and inflation further complicate attempt to provide support by the grassroot organizations, and have exacerbated existing individual vulnerabilities. Consequently, many street-based sex workers in Brussels lack agency in crucial decisions such as entering or exiting sex work, selecting clients, and accepting working conditions, leading to adverse safety and health outcomes, including stress, substance use, gender-based violence, inconsistent condom use, STIs, and psychological health issues.

The decriminalization of sex work, advocated by numerous grassroots organizations supporting street-based sex workers in Brussels, has been perceived as essential for granting individuals greater autonomy over their work environment. This includes the ability to choose clients, workplaces, working conditions, and the duration of their career. However, decriminalization alone has proven inadequate in addressing the contextual and structural challenges faced by many individuals in achieving goals related to occupational safety, health, well-being, and decent working conditions.

Similar observations have been noted in previous research conducted in an other decriminalized setting, where decriminalization alone was found to be insufficient in addressing common obstacles to safety and health. However, these studies predominantly focused on intervention to primarily tackle stigmatization, rather than addressing individuals' structural vulnerabilities [57].

Other studies have underscored the necessity of structural interventions beyond the scope of sex work decriminalization and universal health coverage. The aims of such interventions are to improve the economic and social circumstances of sex workers, reduce preventable harm, improve health outcomes and empower individuals [58,59,60]. Schwartz et al. advocate for a comprehensive and “multi-component” approach to address the multifaceted nature of individuals' environments influenced by various factors [61]. They stress the importance of structural interventions as a critical component in overcoming barriers to enhanced health and safety outcomes, as well as resilience, and autonomy. This involves modifying economic, political, legal, or social environments. This approach, advocated within the context of criminalized sex work, aims to address underlying health needs and vulnerabilities, including trauma, by addressing the root causes of health issues within criminalized settings. It applies to both individuals seeking to exit sex work, and to those with formal education and economic alternatives who choose to continue in sex work [61,62].

4.1. Job Demands and Resources

Stakeholders have highlighted numerous negative emotions experienced by street-based sex workers in Brussels, including those who intentionally chose this profession. SSWs encounter barriers to accessing amenities and facilities, such as WASH facilities, food, and seating, as well as safe spaces for waiting, negotiating, and providing services. Frequent street violence and harmful interactions with both "bad clients" and "fake clients" are cited as major challenges in their work environment. SSWs often select places strategically to be easily found by clients, particularly regular clients, and to work under safe conditions, such as the sole remaining love hotel. However, they are frequently directed away from these safe locations by law enforcement, leading to a lack of control over their work environment and increased vulnerability to violence. In addition, several modifications in the urban landscapes have foster increased challenge to work in safe places. Additionally, several modifications in urban landscapes, have led to increased challenges in finding safe places to work, whether intentional or not. Exposure to violence results in short and long-term physical and psychological damage. Stakeholders report feelings of unwellness, neglect, overwhelm, struggling with mental health, the need to disconnect while working, constant fear, and fatigue among SSWs. Many express that the low pay, long hours, and safety concerns make their work unsustainable.

The findings underscore that SSWs have their own organization to facilitate their business and promote their occupational safety, health, and well-being, such as being able to assess clients' reliability, compatibility, and their own safety in secure locations before engaging in any transaction. The frequent exposure to violence is often attributed to the lack of resources available to protect themselves between and during transactions, partly stemming from urban modification. Violence overshadows other critical aspects of their work environment, such as access to resources for meeting basic needs, comfort, and well-being. This overarching safety issue exacerbates vulnerabilities, job constraints, and significantly impacts the well-being and psychological health leading many to lose interest in their work because of the low pay and long hours, which make undertaking safety risks not worth it anymore.

Stakeholders echo observations similar to those of Shannon et al. (2008), emphasizing a differentiation between "good clients" (termed “regular clients”) and "bad clients" (termed "bad dates"). Some SSWs favor regular clients due to the perceived ability to exert agency and control over resources. Conversely, "abusive johns", generally unknown/one-time clients, are depicted as leading to detrimental trade-offs and the victimization of street-based sex workers, highlighting a power disparity between clients and sex workers [63]. The lack of access to resources, such as safe working places has been found to hinder prevention efforts, diminish control over client interactions, heighten the risk of violence, and pose challenges in negotiating condom use, particularly in settings like cars [63]. Despite sex work decriminalization, a recent study revealed that SSWs in New Zealand employ similar strategies to mitigate the risks of violence, such as carefully selecting their work areas, while similarly facing threats from proposed bills aimed at restricting their choice of work locations. Either in this context, it has been found to constrain their agency. Another similarity regards suggested solutions often formulated by individuals outside the industry who overlook the benefits, drawbacks, and barriers perceived by SSWs in different locations [57].

This scenario aligns with the conceptualization of "burnout" by Demerouti et al. (2001), framed through the job demands-resources model [63]. Studies suggest that burnout develops through two processes: excessive job demands leading to exhaustion, and a lack of resources hindering the meeting of demands, resulting in disengagement from work over time. Exhaustion stems from prolonged exposure to intensive strain, including emotional aspects, while disengagement involves distancing oneself from work and developing negative attitudes towards it. Job demands encompass any aspects of work that require sustained effort and incur physiological and psychological costs, such as exhaustion. Job resources, including job control and social support, help achieve work goals and mitigate these costs, acting as health-protective factors. When resources are lacking, individuals struggle to cope with environmental demands, thus hindering goal attainment and health maintenance [63].

Numerous studies on sex workers' health emphasize the importance of community organization along with various external interventions to promote their rights, safety, health, and well-being [9,57,61,64,65]. Literature shows that community empowerment among sex workers involves uniting to advocate for their rights and for access to resources. Developing leadership within sex worker communities is deemed crucial and requires a “multi-level” intervention, such as engagement from both governmental and non-governmental sectors, through political and financial support to provide them with the means to scale up community empowerment initiatives [61,66,67].

Despite sex work decriminalization, attention to street-based sex workers’ occupational safety, health, and well-being remains inadequate compared to formal workers. Future research should explore the short and long-term impacts of the physical environment on street-based sex workers, especially in urban areas undergoing restructuring. Studies should investigate how various workplace factors, such as long waiting hours, adverse weather conditions, seating options, access to facilities, social interaction opportunities, and ergonomic considerations, affect the OSHW of this population, before, during, and after providing services. These aspects, often overlooked in research, are crucial for understanding and enhancing their safety, health and well-being.

4.2. The “Stigma System”

Following urban restructuring, one of the main SSW’s areas experiences an influx of individuals with diverse social issues. This blend, combined with decreased social activity, exacerbates petty crime and safety concerns, diminishing the neighborhood's allure for tourists and impeding apartment rentals for tourists. A neighborhood committee blames SSWs for these issues and initiates an aggressive anti-sex work campaign, supported by the mayor's issuance of outdated regulations that contradict decriminalization laws, enforced by the police. Motivated by ideological convictions, these actions aim to dissuade SSWs from operating in the municipality, obstructing their access to essential resources, deterring businesses from accommodating them and their clientele, and driving them away. Despite the vice squad collaboration to promote street-based sex workers’ protection and well-being, their efforts are hindered by a lack of political will to implement further protective measures. Acting on municipal orders, the local police employ harmful strategies, forcing SSWs into hiding and limiting their choices in their work environment, or discouraging them from reporting instances of assaults, compromising their safety and exacerbating poor health outcomes. This strained relationship with law enforcement leads SSWs to distrust them and to refrain from calling them when they should, while local NGOs have failed to overturn unlawful regulations due to impending elections.

These findings underscore a significant power imbalance, depriving street-based sex workers of their newfound rights conferred to them by decriminalization laws. Portrayed as the cause of neighborhood insalubrity and criminality, they face harassment, exaggerated accusations, and violence and humiliation at the hands of both the neighborhood committee and law enforcement. While rooted in ideological convictions, the anti-SSW campaign is also driven by vested interests, such as financial gain for the neighborhood committee and reelection for the municipality. Unlawful regulations endorsed by the municipality gradually strip SSWs of their rights and advantages, including harm reduction and protective resources, resulting in poor OSHW outcomes and the exclusion from the neighborhood's social life.

Research from decriminalized settings in Australia and New Zealand reveals that decriminalization fails to shield SSWs/SWs from harassment, including from so-called "vigilante groups" or "concerned citizens" in New Zealand. These groups wield enough power to influence the political agenda, threatening street-based sex workers’ autonomy in choosing their WE [25,57,68].

The convergence of labeling and stereotyping, segregating and depriving populations of their rights while fostering discrimination in a context that allows it, is conceptualized by social science as stigma [69].

Literature demonstrates that the stigma experienced by street-based sex workers persists in other decriminalized countries, often exerting more influence than decriminalization laws themselves on SSWs’ rights, further diminishing their power within their work environments [44,57]. Discriminatory attitudes and policies often curtail legal protections and access to support and perpetuates power imbalances, rendering SSWs more vulnerable to exploitation and harm, even in decriminalized settings [68,70].

Despite variations in legal frameworks, local policing strategies that isolate sex workers hinder their agency in negotiating condom use and serve as structural barriers to HIV prevention. Additionally, these strategies have been linked to further negative health outcomes and increased rates of violence from clients across stigmatized populations [36,57,65,69,71].

Enforcement-based crackdowns often result in rights violations, unlawful harassment, and gender-based violence. A major implication of this relationship with law enforcement is that the enforcement of rights for street-based sex workers following victimization is frequently disregarded or not pursued, perpetuating marginalization and power imbalances [70]. The complex social processes perpetuating stigma and resistance to sex work decriminalization form a "stigma system," a multilevel system where individual, organizational, ideological, and macrosocial conflicts interact dialectically [69].

Stigma systems against street-based sex workers, or scapegoating of already-stigmatized groups, coincide with vested interests among stakeholders and serve as effective tools for the powerful to perpetuate inequality and accumulate privilege, financial gain, and political aspirations [25,57,69,72]. Friedman’s “stigma system” theoretical framework on stigmatization underscores the importance of grassroots NGOs advocating for SSWs' rights, representing pivotal sociopolitical forces opposing stigma [69].

Despite literature often portraying police negatively in street-based sex work contexts, this study highlights the vice squad's significant role in the well-being and lives of SSWs. Studies should investigate stakeholder attitudes and their impact on SSWs’ occupational safety, health, and rights enforcement, thus identifying challenges and tools for achieving their goals towards SSWs in a context of sex work decriminalized.

5. Conclusions

Overall, the sex work decriminalization law has made modest steps towards improving the working environments, as well as the OSHW of street-based sex workers in Brussels. Significant structural vulnerabilities, safety concerns, stigmatization, and challenges in the enforcement of their rights enforcement persist, resulting in overall poor working conditions and health outcomes. Instances of violence, and a rise in sexually transmitted infections further exacerbate physical and psychological health issues among SSWs.

6. Future Directions

Future research should include the active involvement of street-based sex workers to explore their specific needs concerning occupational health, safety, and well-being. It should also examine the roles and impacts of various stakeholders in supporting street-based sex workers' occupational safety, health, and well-being, identifying the needs for interventions, factors that facilitate progress and barriers that hinder it.