From 9,148 papers identified, 134 studies met the inclusion criteria, resulting in 40 papers included in the quantitative synthesis, of which 20 were included in the meta-analysis and 20 in the narrative synthesis. A total of 94 met the inclusion criteria for the qualitative synthesis, of which 46 were included in the thematic analysis, 3 were excluded following quality assessment, and 45 were excluded when thematic saturation had been reached (Fig 1).

Two studies in Canada evaluated a new policing guideline that prioritised enforcement of laws against clients and third parties over arrest of sex workers introduced in Vancouver in 2013. These studies found that there was no decrease in physical and sexual violence (OR 1.09, 95% CI 0.59–2.04, p = 0.78) among participants surveyed after 2013 compared to those surveyed before, but there was increased report of rushed negotiations with clients due to police presence (OR 1.73, 95% CI 1.03–2.90, p-value not reported) [ 57 , 92 ]. The introduction of an anti-trafficking policy in South Korea, accompanied by brothel closures, in 2010 was associated with a decrease in prevalence of gonorrhoea and antibodies to Treponema pallidum (indicating current or past infection), but also changes in the demographic profile of sex workers. Sex workers were younger in surveys conducted after the act compared to before, which may contribute to the lower prevalence of infection, although sex workers reported receiving more clients [ 77 ].

Four studies reported associations between mandatory registration at a city health service in Tijuana, Mexico and health outcomes [ 79 , 81 , 89 , 90 ]. One study suggested that registered sex workers had reduced odds of working in a sex work venue with high prevalence of HIV or syphilis and testing positive for HIV or an STI (syphilis, gonorrhoea, or chlamydia) univariably. These associations became insignificant after adjusting for injecting risk behaviours, age, and time in sex work [ 79 ]. Of note, sex workers who test positive for HIV in this system have their registration revoked, and sex workers already living with HIV cannot work in the regulated sector; therefore, sex workers who know or suspect they are living with HIV are unlikely to register. Registered sex workers had reduced odds of ever injecting drugs and higher odds of being tested for HIV [ 81 ]. A final study suggested that lack of registration was associated with increased odds of unprotected sex (OR 2.1, 95% CI 1.2–3.5, p-value not reported) [ 90 ].

Five studies examined the association between repressive policing practices and drug use including injecting drug use [ 60 , 66 , 86 , 87 ], the use of non-prescription opioids [ 27 ], and excessive alcohol drinking [ 60 , 66 ]. All of these studies showed a positive association between exposure to repressive policing practices and drug/alcohol use. One study among cis female sex workers in Mexico who inject drugs found a positive association between police confiscation of needles/syringes and injecting in public places (linked to increased risk of skin and soft tissue injuries but reduced risk of overdose) (OR 1.6, 95% CI 1.1–2.4, p-value not reported), as well as injecting in the groin area (linked to increased risk of overdose) (OR 1.9, 95% CI 1.2–2.9, p-value not reported), but reduced odds of injecting with clients (potentially linked to sharing needles/syringes but reduced risk of overdose) (OR 0.64, 95% CI 0.44–0.94, p-value not reported) [ 63 ]. Another study with the same population found that confiscation of needles/syringes was associated with lower safe injection self-efficacy at 8 months (−0.51, SE 0.25, p = 0.04) [ 62 ]. Recent history of incarceration was associated with use of crystal methamphetamine among cis female sex workers in Iran [ 86 ].

Three studies looked at indicators of emotional ill health. In India, cis female sex workers mostly working on the street who had been arrested had increased odds of major depression (defined through Patient Health Questionnaire–2) (OR 1.6, 95% CI 1.1–2.3, p = 0.05) compared to those who had not been arrested [ 88 ]. In Canada, recent incarceration was associated with poor emotional health outcomes among both cis and trans female sex workers in a univariable analysis (OR 1.55, 95% CI 1.12–2.14, p < 0.10) [ 60 ]. Among the same population, individuals who reported that the police had affected where they worked had increased work stress compared to those who did not report this [ 55 ].

Five studies looked at the association between repressive policing activities and access to health and social care services. One study in India found that arrest in the last year was associated with increased odds of attendance at an STI clinic (OR 1.74, 95% CI 1.02–2.98, p = 0.04) [ 71 ]. Confiscation of needles/syringes in Mexico by the police was associated with increased odds of having an HIV test among sex workers who inject drugs (OR 1.49, 95% CI 1.09–2.05, p-value not reported) [ 63 ]. In Canada, fear of police and police harassment, including arrests, was associated with avoiding healthcare services among street-based cis women [ 85 ] and cis and trans women [ 61 ]. Geospatial analyses among the same population showed that a higher density of police enforcement practices (including displacement, legal restrictions of sex work areas, and police harassment) was associated with disrupted HIV treatment [ 56 ]. In Uganda, rushed negotiations with clients due to police presence was associated with less frequent dual contraceptive use (OR 0.65, 95% CI 0.42–1.00, p = 0.05) [ 83 ]. In a study in China, where HIV testing is mandatory following detention, history of arrest was associated with increased odds of having an HIV test or taking up HIV prevention interventions, but fear of arrest was associated with decreased odds of both HIV testing (OR 0.78, 95% CI 0.55–1.12, p = 0.18) and accessing prevention interventions (OR 0.39, 95% CI 0.22–0.68, p < 0.001) [ 80 ].

The overall association between repressive policing activities and condom use increased when pooling unadjusted estimates from 2 studies (OR 1.76, 95% CI 1.30–2.38, I 2 = 0.0%, 95% CI 0.0%–0.98%, p = 0.46) ( S3 Fig ). Sub-group analysis suggested that the odds of condomless sex with clients was higher following policing exposure (OR 1.42, 95% CI 1.03–1.94, I 2 = 63.3%, 95% CI 0.0%–98.2%, p = 0.04) or when additional money was offered (OR 1.54, 95% CI 1.10–2.15, I 2 = 66.7%, 0.0%–97.8%, p = 0.03). There was no difference in the odds of condomless sex with non-paying partners after police exposure (OR 1.0, 95% CI 0.80–1.24, I 2 = 0.0%, 95% CI 0.0%–17.7, p = 0.97) ( S4 Fig ).

Five studies measured the association between repressive policing activities and condom use with both paying and non-paying partners. Meta-analysis of 4 independent multivariable estimates (9,447 participants) suggested that on average these practices were associated with increased odds of not using a condom (OR 1.42, 95% CI 1.03–1.94), with moderate heterogeneity across the studies (I 2 = 63.34%, 95% CI 0.0%–98.2%, p = 0.04) ( Fig 4 ).

This overall association between police repression and violence increased slightly, but was still associated with substantially higher odds of violence, when all unadjusted estimates were pooled from 6 studies (OR 3.15, 95% CI 1.99–4.99, I 2 = 78.7%, 95% CI 52.5%–97.4%, p < 0.001) ( S2 Fig ). Odds of experiencing physical or sexual violence by other people (defined as anyone other than paying clients, including the police) was higher for those who had experienced any type of repressive police activity compared to those who had not (OR 3.72, 95% CI 1.74–7.95, I 2 = 84.1%, 95% CI 53.5%–99.0%, p < 0.001). Similarly, physical or sexual violence from clients was higher among those who had been exposed to repressive police activity compared to those who had not (OR 2.71, 95% CI 1.69–4.36, I 2 = 80.4%, 95% CI 45.5%–96.3%, p < 0.001) ( S4 Fig ).

We pooled data from 9 studies that measured the association between repressive policing activities and experience of physical or sexual violence against sex workers by a range of perpetrators, including clients, intimate (sex) partners, and police. Random effects meta-analysis of 9 independent multivariable estimates showed that, overall, repressive policing was associated with substantially higher odds of any kind of violence (5,204 participants, OR 2.99, 95% CI 1.96–4.57), but with high heterogeneity (I 2 = 83.1%, 95% CI 65.3%–96.0%, p < 0.001). Sub-group analysis suggested that those who had their needles/syringes or condoms confiscated had higher odds of violence than those who did not (1,696 participants, OR 4.67, 95% CI 1.32–16.54, I 2 = 93.9%, 95% CI 76.2%–99.8%, p < 0.01) ( Fig 3 ).

The overall effect estimate of repressive policing actions on HIV/STI outcomes was maintained across sensitivity analyses including those focusing on unadjusted estimates (OR 1.85, 95% CI 1.49–2.30, I 2 = 14.0%, 95% CI 0.0%–81.1%, p = 0.32) ( S1 Fig ), those focusing on HIV outcomes only (OR 1.88, 95% CI 1.54–2.28, I 2 = 0.0%, 95% CI 0.0%–0.0%, p = 0.98), and those excluding self-reported STI symptoms (OR 1.91, 95% CI 1.58–2.31, I 2 = 0.0%, 95% CI 0.0%–0.0%, p = 0.99) ( S4 Fig ).

Meta-analysis of 12 independent multivariable estimates showed that any type of repressive police practice was associated with twice the odds of HIV/STI (12,506 participants, OR 1.87, 95% CI 1.60–2.19), with little heterogeneity between studies (I 2 = 0.0%, 95% CI 0.0%–0.0%, p = 0.99). Sub-group analysis suggested that people who had their needles/syringes or condoms confiscated had higher odds of HIV/STIs than those who did not (2,924 participants, OR 2.44, 95% CI 1.76–3.37, I 2 = 0.0%, 95% CI 0.0%–0.0%, p = 0.99). Sex workers who had experienced sexual or physical violence from police had higher odds of HIV/STI compared to those who had not (1,827 participants, OR 2.27 95% CI 1.67–3.08, I 2 = 0.0%, 95% CI 0.0%–98.6%, p = 0.79) ( Fig 2 ).

We identified 40 studies that measured the association between an aspect of police repression of sex workers or their clients and our outcomes of interest. The majority of the studies were cross-sectional (28) or serial cross-sectional (2); there were 9 prospective cohorts [ 27 , 54 – 61 ] and baseline data from 1 randomised control trial [ 62 ]. Studies were conducted in a variety of countries representing some but not all of the main sex work legislative models ( Table 1 ). Partial criminalisation was represented in 10 studies in Canada, 6 studies in India, 3 studies in Russian Federation, 2 studies in Argentina, and 1 each in Côte D’Ivoire, Spain and UK. Full criminalisation was represented in 3 studies in Uganda, 2 studies in China, and 1 each in Iran, Rwanda, and South Korea. Regulation models were represented by 8 studies in Mexico. No quantitative studies examined the effects of the criminalisation of sex purchase in isolation, or the effects of decriminalisation. Outcomes reported included the following: sexual or physical violence (n = 10) [ 57 – 59 , 63 – 69 ], HIV and/or STI prevalence (n = 15) [ 54 , 60 , 63 , 67 , 70 – 78 ], condom use (n = 5) [ 71 , 74 , 78 – 82 ], access to services (n = 8) [ 56 , 61 , 63 , 71 , 80 , 83 – 85 ], aspects of drug use (n = 6) [ 27 , 46 , 62 , 63 , 66 , 86 , 87 ], and emotional ill health (n = 3) [ 55 , 60 , 88 ]. Two studies focused on the association between criminalisation and social and criminal justice factors including further extortion by the police or history of arrest [ 63 ], any contact with the criminal justice system, being a migrant, and unstable housing [ 60 ]. The majority of studies focused on cis women, with the exception of 6 that included trans women (n = 5) and cis men (n = 1) in Canada and Argentina [ 27 , 55 , 56 , 60 , 61 , 70 ]. Location of sex work was diverse across street and off-street settings. All studies reported an association between lawful or unlawful repressive police actions towards sex workers and outcomes, of which 21 adjusted for confounders. We synthesised 4 studies that reported an effect estimate associated with a mandatory registration separately [ 79 , 81 , 89 , 90 ] but considered lawful and unlawful repressive police activities within the regulatory system as part of the pooled analysis [ 63 , 72 , 91 ]. Three studies presented effect estimates associated with a policy change, STIs, and rushing negotiation with clients, and were also considered separately [ 57 , 77 , 92 ]. Twenty studies reported on outcomes relating to HIV/STI prevalence, violence, and condom use, on which our primary meta-analyses are based. Characteristics of all studies are summarised in Table 2 .

Qualitative synthesis

Included qualitative studies. From the 94 eligible papers including qualitative data, we generated 4 core analytical categories over 37 unique analyses (papers) in different legislative frameworks and geographical settings, refining these through the inclusion of a further 9 purposively sampled papers (S3 Text). Studies were undertaken in a range of legislative models: Full criminalisation models were represented in 3 papers in the US; 2 papers each in Cambodia, Kenya, Serbia, South Africa, and Sri Lanka; and 1 paper each in Australia, China, Nepal, Pakistan, Uganda, and Zimbabwe. Partial criminalisation models were represented in analyses from 5 papers in Canada and 1 paper each in Hong Kong, India, Nigeria, Thailand, and the UK. Five papers focused on Canada following the introduction of criminalisation of clients, and 1 on Sweden, where that model is in place. Regulatory models—which criminalise those non-compliant with regulations including tolerance zones, regulated venues, and/or mandatory registration at a health care facility—were represented by 2 papers each from Australia, Guatemala, Mexico, and the US and 1 from Turkey. Four papers related to New Zealand, where sex work has been decriminalised. In total, interviews with 2,199 sex workers were analysed, representing a range of sex work locations (including street settings, truck stops, brothels, massage parlours, bars, night clubs, hotels, lodges, and homes) and means of meeting clients (including organised in person, via phone or online, independently, and via third parties). Most studies focused on cis women exclusively (n = 25), with a minority including sub-samples of trans women or transfeminine people (n = 18) or cis men (n = 9). Just 2 papers focused exclusively on the experiences of trans sex workers, and 1 on male sex workers. Ten studies included interviews with other actors associated with sex work, including clients, venue managers/owners, police, and outreach workers, but our analyses focused on data from sex workers themselves. Characteristics of included studies (data-rich and purposively sampled) [22,26,34–36,49,93–132] are summarised in Table 3, indicating which papers were purposively selected. A list of the other papers that were identified but not included is available (S3 Text). PPT PowerPoint slide

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larger image TIFF original image Download: Table 3. Summary of qualitative study characteristics included in the thematic analysis including legislative context and methods. https://doi.org/10.1371/journal.pmed.1002680.t003 Core analytical categories identified include disrupted workspaces and safety strategies; institutionalised violence, coercion, and extortion, and restricted access to justice; reproduction of multiple stigmas and inequalities; and restricted access to health and social care and support (S4 Text). Illustrative quotes from the core categories are summarised in Box 1.

Core category 1: Disrupted workspaces and safety strategies. In contexts of full or partial criminalisation, laws against soliciting or communication in public places for the purpose of prostitution—and feared or actual arrest—compromised street-based sex workers’ safety by rushing or displacing client screening and negotiations to secluded places, resulting in greater vulnerability to violence and theft by clients and others (Quote 1) [22,98,121,122,125,130]. For sex workers operating indoors, these laws impeded direct negotiations with clients and communication between peers about safety and sexual health [121]. This pattern persisted in contexts where clients were criminalised. Since it was in clients’ and sex workers’ mutual interest to avoid police detection, and because increased police presence and reduced number of clients led to the need to work longer hours [34,114], sex workers limited, rushed, or forewent usual client screening and negotiation, and were displaced to more isolated areas, increasing their exposure to violence and sexual health risks (Quotes 2, 3, 4a, and 4b) [34,114]. In Canada, cis and trans female sex workers continued to be displaced by police in areas undergoing gentrification, and, even when they were not targeted, some still experienced police presence as harassment [26,114]. Across diverse contexts, experience of possession of condoms being used as evidence of sex work, and experience of police raids where condoms had been confiscated, led to sex workers not carrying, using, or accessing condoms consistently [93,98,106,109] and venues restricting or not providing them [93,98,109,118]. In South Australia, sex workers attributed the latter to increased raids, closures, and the recent arrest of a venue owner [98]. Laws against brothel-keeping and bawdy houses left sex workers in the UK [123] and Canada [102,121] having to choose between working safely with other sex workers and/or third parties (e.g., security guards and drivers) and avoiding arrest by working in isolation (Quote 5), and deterred venue managers from providing sexual health training and supplies [93,121]. A lack of legal protection left sex workers vulnerable to exploitation by venue managers who could restrict access to information on their working and legal rights [121,123]. Anti-trafficking policies in Cambodia and attempts to ‘eliminate’ sex work in China resulted in police crackdowns on brothels, which displaced sex workers to unfamiliar and sometimes isolated locations (e.g., the street, bars, massage parlours, and private accommodations) where, working alone, they had less protection and control over negotiations with clients, lacked peer support to establish collective norms on condom use (Quote 6a and 6b), and were more vulnerable to sexual and other violence both from police and perpetrators posing as clients [110,117,118]. In Guatemala, some venue managers warned sex workers about raids, but, in common with experiences in Sri Lanka [120], others encouraged them to provide officers free sexual services to avoid their prosecution [132]. In India, some brothel owners paid police to avoid raids, or allowed pre-selected sex workers to be arrested [99]. Police harassment, raids [35,110,120], undercover operations, entrapment, and pressure to act as informants [97,128] generated fear, anxiety, and stress, with media sometimes publicising sex workers’ faces during raids [120]. Conversely, where certain indoor work places were informally approved by police in a wider landscape of criminalisation, as occurred in low-barrier housing for women in Canada, the removed threat of criminal penalties fostered venue-level safety strategies, in which sex workers could refuse unprotected sex or call the police in the event of a client becoming violent (Quote 7) [113]. Similarly, in the context of decriminalisation in New Zealand, cis female sex workers working on the street reported greater police presence contributing to their protection as well as increased time for screening clients (Quotes 8 and 9) [36,94–96]. Sex workers across sectors reported being able to negotiate services more directly and refuse clients [36]. Police became more focused on sharing information with women about violent incidents or individuals, and when their presence was off-putting to clients, women could request that they left [96]. Sex workers working outdoors no longer needed to move to isolated areas [94], although they continued to experience verbal and physical abuse by passers-by [95]. Although sex worker organisations objected to mandatory condom use within this model, some sex workers felt that it helped them insist on condom use [36]. In contexts of regulation in Australia, Mexico, and the US, venue-level systems such as alarms, fixed prices, intercoms, and condom use [100,124], as well as being able to work in close proximity with other sex workers and third parties [35,100,101,124], improved control and sense of safety for those able to work in regulated venues. Yet, in the US, some women criticised such systems as a veiled means of surveillance and as protecting management and clients’ interests above their own safety [100]. Across these settings, those unable to conceal venue-prohibited substance use were excluded from these premises and left as the authors note with ‘no choice but to work on the streets’ [124] or in the minority of venues where management overlooked these regulations [35,100,101]. In Canada, the cost of business licenses and the ineligibility of those with criminal records restricted access to and mobility between regulated venues [93,121]. In Mexico, only well-networked, resident, HIV-negative, cis female sex workers gained access to tolerance zones and regulated venues, which offered fewer physical risks than unregulated indoor and outdoor settings but were often overcrowded, making income less stable [35,101]. In Australia, Guatemala, and Mexico, the ineligibility of minors to work in regulated venues meant that they had to work on the street [35,124,126]. In Australia and Sri Lanka, sex workers operating in unregulated venues had less control over negotiations with clients, and some owners encouraged women to provide sex without a condom [124,120].

Core category 2: Institutionalised violence, coercion, and extortion, and restricted access to justice. Studies showed that policing practices in contexts of criminalisation and regulation institutionalised violence against sex workers, both directly through police inflicting physical or sexual violence or demanding fines in lieu of arrest, and indirectly by restricting access to justice and thus creating an environment of impunity for perpetrators of violence [97,102,122,125,127–130]. Violence and abuses of power by police were reported across all genders and diverse political and economic contexts, including Cambodia, Canada, the Democratic Republic of the Congo, India, Kenya, Nepal, Nigeria, Pakistan, Serbia, South Africa, Sri Lanka, Thailand, Uganda, the US, and Zimbabwe [49,97,99,104,106,111,112,118,119,122,125,127,128]. This took the form of arbitrary arrest and detention, verbal harassment, intimidation, humiliating and derogatory treatment, extortion, forcible displacement, physical violence, gang rape, and other forms of sexual violence during raids and in police custody [49,97,99,103,104,106,111,112,118,122,127,128]. In Kenya, Mexico, Nepal, Pakistan, Serbia, Sri Lanka, and the US, sex workers experienced extortion (unofficial ‘fines’, payments, or bribes) or provided sexual services enforced through physical or sexual violence or under threat of detention, arrest, transfer to rehabilitation centres, or forced registration (Quotes 10 and 11) [49,101,103,110,119,122,128–130], with limited or no opportunity to negotiate condom use [128]. Similar extortion and/or arbitrary fines were reported in China, India, Thailand, and Turkey (Quote 12) [99,107,110,125]. In Nepal, cis female sex workers, including those hired as peer educators, reported being arrested, beaten, and robbed by police upon being found in possession of condoms [106]. Reporting violence could result in sex workers’ being further criminalised [49,97,120–122,127,128]. Sex workers were reluctant to report violence and theft to the police [98,125] for fear of the following: arrest for prostitution-related activities, unrelated petty offences, or non-payment of previous fines [97,98,116,120,124,131]; being accused of crimes they had not committed [49,103]; harsh treatment or moral judgement [97,120]; further extortion or violence [35,101,112]; disclosure in court [97]; prohibitive costs [112]; or because no action would be taken to address the crime [97,111,112,114,116]. Long-standing discrimination, and the sense that police viewed them as criminals, made sex workers doubt the police would take complaints seriously [114,115,128]. When reports were submitted to police, sex workers’ accounts were dismissed as implausible, with police simultaneously blaming sex workers for the violence they had experienced [49,120,125], discrediting them as victims (Quote 13) [97,103,121,127,128], and sometimes further attacking or extorting them [49]. Cis and trans women in Canada and the US reported police questioning whether it is possible for a sex worker to be raped [97,128]. (Quote 14). Similarly, in Kenya, one cis woman reported being asked by an officer ‘how a prostitute like me could be raped as I was used to all sizes’, discouraging her from going to the police in future: ‘Never will I again go to report a case’ [127]. This produces an environment of impunity, where further violence, extortion, and theft from police and others operate unchecked [98,103,120,121,125,127], perceived to be a major contributor in normalising violence against sex workers [26,125]. Reluctance to report violence occurred even in contexts where the purchase but not the sale of sex was criminalised, due to fears that information about where sex work takes place could be used to target clients and harass sex workers (Quote 15) [34,114]. While some cis and trans women in Canada felt that police were now more concerned for their safety [26,114], others felt that officers continued to view them as ‘trash’, blame them for the violence they experienced, and deprioritise their safety [97], despite laws and police guidelines constructing them as victims [26]. In contexts of regulation, registered sex workers in Guatemala viewed their health cards (recording compliance with mandatory testing) as protective against police and immigration harassment [126,132], and registered sex workers in Mexico had better access to police protection but rarely reported violence [35]. In Senegal, registered workers still experienced being disbelieved when reporting physical or economic violence to police and so were reluctant to report it as a result (Quote 16) [105]. Concerns about being exposed to family and friends were paramount [35,105] and deterred some from registering [126]. Relationships with police were precarious, conditional on maintaining registered status, which can vary each month depending on compliance with mandatory screening requirements—with those whose registration has (temporarily) lapsed facing arrest, detention, and/or fines (Quote 17) [35,126]. Those who were not registered were afraid they would be sent to jail or fined for working illegally, or for active drug use [35], and were more heavily targeted by police for fines, arrest, detention, extortion, and sometimes sexual violence [35,101,124]. In India, marked reductions in police raids and violence were achieved through a peer-based intervention that facilitated access to justice and challenged power relations between sex workers and police, although some officers cited lengthy procedures to dissuade reporting [99]. In Canada, Mexico, Thailand, and the US, some sex workers described certain officers’ concern for their safety and support, but such concern was the exception [35,97,103,125]. Since decriminalisation in New Zealand, sex workers describe having better relationships with the police, and greater access to justice which—despite some prevailing mistrust in police—makes them feel safer and more confident with clients [36,95,96] and more deserving of respect (Quote 18) [36]. The removal of threat of arrest—which reduced police power and afforded sex workers rights—gave sex workers, and particularly young people [95], greater confidence to report violent incidents, exploitation by managers, and disputes with clients [36,96]. However, some officers treated disputes with clients as breaches of contract rather than crimes [96]. While there were still some reports of abuses of police power, there were also examples of offending officers being prosecuted as a result, helping to challenge environments of impunity [36,94,96].

Core category 3: Reproduction of multiple stigmas and inequalities. Findings show that repressive police treatment reinforced inequalities and entrenched marginalisation of sex workers, as well as creating disparities within sex-working communities, with police targeting specific settings or populations. In the context of full criminalisation in Sri Lanka, sex workers reported experiencing harsher punishment than their clients or managers: both sex workers and clients might be fined, but clients were not arrested or charged in the way that sex workers were [49], nor were managers of flats arrested during police raids [120]. Across settings, arrests, fines, extortion, and theft by police particularly targeted street-based sex workers [101,103,120,128], resulting in loss of income and increased economic vulnerabilities (Quote 19) [49,99,103,118,125,127,129,130]. Findings from Canada, Sri Lanka, and the US also show how criminalisation and police enforcement restricted freedom of movement, as sex workers were targeted arbitrarily by police during and outside of sex work hours and environments [49,97,103,120,128], and outed as sex workers by officers [97]. Studies showed how police targeting and mistreatment of sex workers, and inaccessibility to justice, reproduced inequalities and discrimination against sexual and gender minorities [26,49,116,119,127,129,130], people who use drugs [22,103,128,133], women, people of colour, and migrants [26,34,97,98,128,129,132]. In Serbia, Roma trans sex workers were treated with ‘contempt’ both by police enacting ‘extreme violence’ against them and by clients who expected cis women (Quote 20) [129]. In sub-Saharan Africa, male and trans sex workers described the ‘double stigma’ they faced, which could result in humiliation, ostracisation, eviction, and lack of access to micro-finance schemes, and this was worse in settings where homosexuality is also criminalised (Quote 21) [127]. In Sri Lanka, where both sex work and homosexuality are criminalised, trans sex workers were less likely to be charged than cis women but they experienced extensive extortion, humiliation, false accusations of crime, and verbal, physical, and sexual violence by officers targeting their gender expression (Quote 22) [49,120]. Similar experiences were reported among feminine-presenting male and trans sex workers in Pakistan and among trans women and sex workers of colour in Canada and the US [26,119,128]. In Canada, trans sex workers attributed officers’ lack of response to their reports of violence to the stigma and discrimination surrounding their gender, sex work, and drug use, reinforcing their self-blame [116]. Long-standing racial discrimination and community mistrust reinforced black and indigenous sex workers’ doubts that the police would take their complaints of violence seriously [26,128], and drug use was used to undermine sex workers’ testimony against their attackers (Quote 23) [128]. In the US, one woman described what police said to an ex-boyfriend who had beaten her up: ‘You can’t go hitting her, even though I’d hit her for being a junkie’ [128]. In Canada, a cis female independent sex worker described a police officer calling her ‘just a fat…native whore’ [97], while some white male independent sex workers attributed their lack of police attention to their race and social and economic privilege [102]. In criminalised and regulated settings, the precarious legal status of undocumented or unregistered migrant sex workers was used by clients [127] and venue owners [132] to refuse payment, and by landlords to charge inflated rents for substandard rooms [107]. Migrant sex workers did not report violence and other crimes to the police due to fear of deportation [35,131,132] or language barriers [98]. In Guatemala, police officers sometimes rounded up migrant sex workers whether or not they were registered [126], and in Turkey, police targeted ‘foreign-looking’ women presumed to be migrant sex workers [107]. In Sweden, immigration legislation and anti-trafficking policies have been used to deport migrant sex workers, despite their characterisation in national prostitution law as victims of violence, as a way of reducing sex work [34].