INTRODUCTION

Sex worker organisations worldwide define sex work as a contractual agreement on sexual services between consenting adults (GNSWP, 2021; UNAIDS, 2009). The term sex worker (Nagle, 2018) refers to a person who engages in commercial sex, consciously considering this occupation a source of income (Berg, 2014). Sex workers face health, social and human rights disparities (Armstrong, 2017; Marshall, 2016; Platt et al., 2018; WRC, 2016) that can only be properly identified under an intersectional lens (Harari and Lee, 2021), taking a community-based approach, namely collaborating directly with sex workers to address their challenges, enhancing working conditions, and offering support (Garofalo Geymonat and Macioti, 2016). By intersectional we mean the multiple, interconnected and changing social identities sex workers carry (Bowleg, 2021; Harari and Lee, 2021) and the stigma they face (Chandler et al., 2022; Jackson-Best and Edwards, 2018), that construct distinctive experiences of adversities (Boonzaier, 2019; Rosenberg and Bakomeza, 2017). Among the many factors affecting the intersecting forms of oppression in sex work are the type of sex work and the social context, like the relevant legislation (Altay et al., 2021). Of many sex work types (Harcourt and Donovan, 2005), the most prominent are brothel- and street-based (Platt et al., 2018; Weitzer, 2017). Brothels are venues where sexual services are offered, usually operating in rented or privately owned apartments or houses, managed by individual sex workers or by third-party operators (Abel and Ludeke, 2020). Street-based sex workers, on the other hand, meet clients in several areas and usually negotiate with them on the street or in a vehicle (West et al., 2022).

This present and retrospective qualitative and quantitative community research aims to identify the specific issues and propose individualised care interventions designed for street-based sex workers in Athens. It was conducted on one specific site, the Red Umbrella Centre in Athens, which is a day centre for sex workers, providing assistance, advocacy, and resources to promote their health, safety, and well-being, operated by the Greek Association of People Living with HIV, called Positive Voice. The centre, now situated at Michail Voda 200 in Athens, benefited from funding provided by the Bodossaki Foundation for a certain period during the research.

Specifically, the study examines how the identities that sex workers carry and how precarity factors they encounter are related to their frame of work, either street- or brothel-based. Aligning with the principles of community-based research this study’s aim derives from the sex work community itself and the need to properly address the disparities and marginalisation street-based sex workers face. More specifically, we investigated how identities like motherhood, migration status and gender identity, as well as precarity factors, such as lack of social network, homelessness, substance use, police issues, client violence, and health and identification papers issues, are associated with each type of sex work.

LITERATURE REVIEW

Sex Work and Intersecting Identities

The sex work type that is within reach for females is, in many cases, related to the different intersecting identities they carry, like gender identity, migration status and motherhood (Goldenberg et al., 2017; WRC, 2016; Zangger, 2015). The non-conforming gender presentation of female trans sex workers limits their employability (Blewett and Law, 2018; Grant et al., 2011; Nadal et al., 2014). It excludes them from the managed sector, including brothels (Zangger, 2015), so trans women mainly work on the street (Wickersham et al., 2017). Migrants, on the other hand, mostly work in indoor venues rather than outdoors, even though they can still be arrested if they work in brothels (ICRSE et al., 2019; Goldenberg et al., 2017; Richter et al., 2014). This seems to be due to the language barrier and lack of industry experience sometimes causing complete dependence on third parties where everything is arranged for them (GNSWP, 2017). Refugees, meanwhile, usually face challenges in the managed sector, with the more serious being their illegal status (Jamil et al., 2012), as well as high levels of distress and pre-existing trauma, caused by the war(s) or oppression that have forced them to flee their homes (Bajwa et al., 2017; Ben Farhat et al., 2018). Finally, sex-working mothers report higher income (GNSWP, 2017; Renshaw et al., 2015) and flexible working hours (WRC, 2016) among the advantages of street-based sex work. That is possibly the reason motherhood is a common identity among street-based sex workers (Duff et al., 2015; Minescu et al., 2022; Renshaw et al., 2015). It also disproves the myth that sex workers, in general, are lonely individuals (Azhar et al., 2020), which represents them as a threat to the social ideals of monogamy and heteronormative family structure (Poulios, 2018).

Sex Work and Precarity Factors

Street-based sex work, however flexible, relates to discrete, often intertwined precarity factors mostly due to the level of work-related exposure and intersectional adversities (Boonzaier, 2019; Easterbrook-Smith, 2020). Street-based sex workers more commonly report homelessness (Aidala and Sumartojo, 2007; Duff et al., 2015; Minescu et al., 2022), as indoor working may not be a feasible option for people without homes. Substance use is also more common among street-based sex workers, because of the strict rules and anti-drug culture of brothels that make the indoor work environment hostile to drug-using sex workers (Sanders et al., 2009). Moreover, the dual criminalisation of street-based sex work and drug use renders sex workers vulnerable to arrests and police harassment (Tomko et al., 2021; Wirtz et al., 2015). Regardless of substance use, though, there is a long history of mistrust between street-based sex workers and the police, due to a history of hostile, unjust actions by police officers (Armstrong, 2017; Logie et al., 2017) and wrongful arrests for vagrancy, public nuisance, stopping the flow of traffic, obscenity and so on (UNAIDS, 2009). Health inequities, experiences of violence and human rights violations are also more commonly reported by street-based sex workers. They are often displaced to isolated, unsafe work environments (Deering et al., 2013; Goldenberg et al., 2017), and their condoms or clean needles get confiscated by police, diminishing access to HIV prevention tools (Logie et al., 2017; Zangger, 2015). Indeed, the prevalence of STIs and the increased risk of HIV infection amongst sex workers has been associated with criminalisation, sexual or physical violence from clients or intimate partners, and condomless sex (Blanchard et al., 2018; GNSWP, 2022; Platt et al., 2018).

It seems that the dangers sex workers face and the behaviours they adopt are associated with the relevant legislation model in place in various countries (Goldenberg et al., 2017; Platt et al., 2018; Tomko et al., 2021), full decriminalisation is argued to create the safest market for sex work (Benoit et al., 2021; Brooks-Gordon et al., 2021). Partial criminalisation models, like the German-Dutch, criminalise some aspects of sex work. However, street-based sex work is almost always criminalised in such legal contexts (Weitzer, 2017), relieving states from their duties to protect sex workers’ human rights, mostly by dehumanising the ‘deviant others’ (Wijers, 2022). Greece is yet another country where partial criminalisation means street-based sex work is illegal and therefore the underground or invisible nature of the activity creates increased risks for sex workers (Jahnsen and Wagenaar, 2019; Law 2734/1999, 1999).

Zeroing in on Greece, the identities that sex workers bear seem to be as related to the frame of commonly assumed sex work as international research has shown in other countries. Trans identity has been shown to limit sex workers in street-based sex work and leave them vulnerable to violence and discrimination (Galanou, 2022). Additionally, Greek Nationality and off-street sex work seem to be operating as protective factors against the worsening mental and physical health of sex workers in the country, especially during the prolonged economic recession (Drydakis, 2022). As mentioned above, not only identities but also precarity factors relevant to work conditions can affect sex workers’ mental health. A Greek study on female sex workers has recently revealed that poor mental health, along with perceived discrimination, is related to non-consensual condom removal (stealthing) which seems to be a quite common danger to sex workers (Apostolidou et al., 2023).

THEORETICAL INSIGHTS

The concept of intersectionality is essential to understanding the intersecting identities and experiences of sex workers. It recognises that individuals embody diverse identities across various social, legal, and cultural dimensions, such as gender identity, ethnicity, and migration status, which intersect to shape their experiences, and enhance marginalisation and vulnerabilities (Altay et al., 2021). In the case of sex workers, the intersection of identities often exacerbates individuals’ exposure to discrimination, violence, and economic exploitation (Boonzaier, 2019; Rosenberg and Bakomeza, 2017). Full decriminalisation, encompassing street-based sex work, as explored in the feminist context, can be seen as a response to these structural vulnerabilities, recognising that punitive laws often contribute to sex workers’ victimisation and lack of agency (Balfour, 2021; Benoit et al., 2021; Brooks-Gordon et al., 2021).

The interplay of sex work and feminism highlights the divergent perspectives within feminist movements. Decriminalisation advocates view it as a means to empower sex workers by affording them legal rights, agency, and the ability to negotiate safer working conditions (Flanigan, 2019). On the other hand, some feminists critique this approach, fearing that it may perpetuate exploitative industries (Comte, 2014). An intersectional approach is pivotal in challenging the stigma surrounding sex work. By acknowledging the unique experiences of marginalised sex workers, street or brothel-based, when it comes to either the identities they carry or the precarity factors they endure, it becomes evident that policy and advocacy must address the specific vulnerabilities and discrimination faced by these individuals (Altay et al., 2021; Benoit et al., 2021). Policy discussions should be informed by the nuanced experiences and perspectives of sex workers themselves, emphasising their agency and autonomy (Urada et al., 2014).

DATA GATHERING

Procedure and Participants

A retrospective study was conducted using data that had been collected at Red Umbrella Centre in Athens. The centre operated under the scientific supervision of the Clinical Research Laboratory: Subjectivity and Social Bond of the National and Kapodistrian University of Athens. The present participant research and paper involve a collaborative effort between academics and researchers of the laboratory as well as employees and volunteers of the centre (Stavroula Triantafyllidou, Paraskevi Siamitrou, Evangelia Ntinopoulou, Anna Apostolidou, Anna Kouroupou, Sofia Kotsia, Anna Papadaki, Giorgos Papadopetrakis, Konstantina Papastefanaki, Aggeliki Sougle, Vaggelis Tsiaras) who are also members of the communities represented in the sample, i.e. sex workers, migrants, substance users, LGBTQ+ individuals etc. In accordance with standard authorship contribution guidelines we delineate each author’s role in this paper. Dr Lissy Canellopoulos and Dr Antonios Poulios provided oversight for both the research endeavour and the writing process of the paper. Stavroula Triantafyllidou, Paraskevi Siamitrou, Evangelia Ntinopoulou, and Anna Papadaki conducted data analysis, drafted the initial manuscript, and contributed to subsequent revisions. Anna Apostolidou, Anna Kouroupou, and Sofia Kotsia managed data curation, while Giorgos Papadopetrakis, Konstantina Papastefanaki, Aggeliki Sougle, and Vaggelis Tsiaras coordinated project management tasks.

The data was collected by a trained member of the staff, a sex worker herself, from July 2021 to December 2022, as part of the initial interview conducted with every new visitor to the day centre. This interview was conducted using the icon-based, culture-free precarity index (Figure 1), which will be further explained in the next section. No reimbursement was given to the visitors for the interview, which was voluntary and anonymous. Participants were asked to give their informed consent to use the data for research purposes.

Figure 1. Precarity index (Source: Red Umbrella Athens). Notes. Condom use refers to problems with clients refusing to use condom, negotiating its removal or removing it during the encounter without consent. Perceived problematic substance use refers to problems with substances interfering with other parts of their lives and an increased level of dependence. Perceived problematic alcohol use refers to problems with alcohol consumption interfering with other parts of their lives and an increased level of dependence. Domestic violence refers to a pattern of abusive behaviors used by a person in a close relationship to gain power and control over them. Homelessness refers to trouble finding or maintaining stable and safe housing, often resulting in them living on the streets, in shelters, or in temporary accommodations like hotels. Medical issues refer to the inability of a person to access medical care, preventive measures, and a healthy lifestyle. Identification papers issues refer to problems obtaining or renewing identification cards, passports, driver's licenses, birth certificates, or other essential documents with implications for access to various services, travel, employment, and legal matters. Client violence refers to various forms of physical, emotional, or verbal abuse, aggression, or harm from their clients. Police issues refer to troubles related to hostile, unjust actions and abuse of power, wrongful arrests, fines and pending formal charges or allegations of a crime or legal violation. Lack of social network refers to limited or minimal connections or relationships with other people, such as friends, family members, or acquaintances whether they know about their profession or not.

It is essential to acknowledge that the present study has not been approved by an ethics committee. The absence of ethics approval does not signify a lack of commitment to ethical considerations but rather underscores the complex dynamics and impediments encountered during the approval process. In Greece, ethics committee approval is not mandatory for retrospective observational studies if the organisation conducting it has had general approval for such studies (De Sanctis et al., 2022). However, factors such as the absence of a single national ethics review committee for research in Greece and the legal restrictions preventing the community organisation in question from establishing an ethics committee (Hellenic Parliament, 2018), contribute to the unattained ethical clearance. Not to mention the intricate nature of retrospective studies, analysing pre-existing data with no control over data collection methods and the committees’ requirement for informed consent that is often an issue in community-based research (Kwan and Walsh, 2018). Despite these challenges, we remain dedicated to upholding ethical standards, ensuring the well-being and rights of the individuals and communities involved by carrying out the study following the ethical guidelines of the Helsinki Declaration on medical research involving human subjects.

In total, a number of 264 cis and trans female sex workers consented to participate and provided valid answers. Regarding gender identity, 87.5% were cis (n = 210) and 12.5% trans (n = 30) women, with an average age of 36.7 (SD = 10.7), as you can see in Table 1. Most of the participants were mothers (68.7%, n = 171). The sample consisted of 61.9% migrants (n = 161), 27.7% (n = 72) locally born and 10.4% refugees (n = 27). In total, 27.7% (n = 72) of the participants were from Greece, 28.1% (n = 74) were from the Balkans, specifically Romania, Albania and Bulgaria, 30.8% (n = 81) were from Russia and Eastern Europe, specifically Ukraine, Moldova, Hungary, Poland and Kazakhstan, 7.2% (n = 19) were Latin American, North African, sub-Saharan African and West European, and the remaining 6.5% (n = 17) were Middle Eastern and South Asian, from Turkey, Iran, Pakistan and Bangladesh. Table 1 presents the participants’ demographics.

Instruments

The icon-based, culture-free precarity index (Figure 1) used in the present study was developed by Red Umbrella Athens based on the early research feedback the community centre received in 2016 from sex workers themselves. Rooted in a genuine community-based research approach, the insights and perspectives shaping the index are exclusively derived from the lived experiences and reflections of sex workers themselves. More specifically, during their initial interviews, sex workers were asked to identify precarity factors in open-ended questions (What are the most frequent challenges you encounter on a regular basis?). The most commonly identified in their responses shaped the precarity factors index used in the present study. The index includes the following precarity factors: perceived problematic substance use, perceived problematic alcohol use, both in terms of interference with other parts of their lives and level of dependence, condom use, homelessness, lack of social network, medical issues, domestic violence, client violence, identification papers issues and police issues. The interviewees respond to dichotomous (yes/ no) questions whether they identify the above factors (e.g., Do you face problems with homelessness/ lack of social network, etc.). The internal consistency of the index was measured using Cronbach’s alpha, which was calculated to be α = 0.646, indicating an acceptable internal consistency. Perceived problematic alcohol use and domestic violence were omitted in the present study due to the high number of missing values.

A questionnaire designed by the researchers with demographic and sex work related questions was also used for data collection. In regard to demographics, the questions included age, gender identity, migration status and ethnicity. Sex work related information like the type of sex work, years of experience, starting age in the industry, other sources of income and part-time work status were also collected.

Statistical Analyses

We estimated absolute and relevant frequencies of the demographic and sex work related variables for the total sample (Field, 2017). The missing values identified were not systematically related to the data, as determined by chi-square tests, indicating that the missing data is random and not associated with the type of sex work, gender identity and migration status (Graham, 2009). Additionally, we assessed statistically significant relationships between demographic variables and the type of sex work (brothel or street-based) using chi-square tests. Finally, we examined statistically significant associations between the type of sex work (brothel or street-based) and the precarity factors reported by the participants using chi-square tests and effect sizes using Phi test when the degree of freedom was 1 and Cramer’s V test when it was more than 1 (Roussos and Tsaousis, 2020). We decided not to use multivariate regression as the assumption of multicollinearity was not met, namely the independent variables were highly correlated with each other.

Statistical significance was set at 0.05 and the analyses were conducted using SPSS Statistics software, version 25.

RESULTS

Sex Work and Demographics

As shown in Table 2, our sample represented adequately the main sex work types as 43.2% (n = 114) worked in brothels and 56.8% (n = 150) worked in the streets. The average age was 36.7 years, ranging from 18 to 71 (Mdn = 34, SD = 10.7), the average years of work in the sex work industry were 6, ranging from 0 to 40 (Mdn = 3, SD = 7.6), and the average entry age in sex work was 31.1, ranging from 13 to 61, (Mdn = 28.4, SD = 11.1). Having other sources of income was reported by 24.5% (n = 34) and 28.1% (n = 43) reported part-time sex work.

Concerning gender identity (Table 3), trans women were more frequently street-based (96.7%, n = 29) rather than brothel-based (3.3%, n = 1), \(\chi^{2}\)(1) = 21.52, p = .000 with medium effect size (Phi = -0.30). Additionally, migration status was related to the type of sex work \(\chi^{2}\)(1) = 58.22, p = .000. More specifically, migrant sex workers were more likely to work in brothels (60.9%, n = 98), while refugee sex workers and local-born were more likely street-based (70.4%, n = 19 and 91.7%, n = 66 respectively), with a large effect size (Cramer’s V = 0.47). Motherhood was not significantly associated with the type of sex work \(\chi^{2}\)(1) = 3.55, p = .060.

Precarity Factors and Type of Sex Work

As shown in Table 4, the majority of women facing perceived problematic substance use (94.6%, n = 53) were street-based \(\chi^{2}\)(1) = 41.45, p = .000, with a medium effect size (Phi = -0.40). Women facing housing problems were also more frequently street-based (78.9%, n = 45), \(\chi^{2}\)(1) = 14.51, p = .000 with a small effect size (Phi = ‑0.23). Of those reporting medical issues the majority (68.1%, n = 64) were working on the street \(\chi^{2}\)(1) = 7.55, p = .006, with a small effect size (Phi = -0.17). Client violence was also more common among street-based sex work (79.5%, n = 31), \(\chi^{2}\)(1) = 9.58, p = .002, with a small effect size (Phi = -0.19), and trouble with the police (79.5%, n = 70), \(\chi^{2}\)(1) = 27.79, p = .000 with a medium effect size (Phi = -0.32).

There were no significant associations between the type of sex work and the existence of a social network \(\chi^{2}\)(1) = 3.40, p = .065, condom use \(\chi^{2}\)(1) = 0.10, p = .764, or problems with legal identification papers \(\chi^{2}\)(1) = 3.53, p = .060.

DISCUSSION

The present study reveals that sex workers in Athens report severe precarity factors, they report multifactorial identities that bring about unique and complex challenges (Boonzaier, 2019). Moreover, street-based sex workers in particular were found to be in an even more precarious position, as street-based sex work was more commonly related to perceived problematic substance use, homelessness, health issues, client violence and problems with the police, as well as trans identity and refugee status.

In line with previous findings (Galanou, 2022; Wickersham et al., 2017; Zangger, 2015), trans sex workers in Athens, in our study, seem to work almost exclusively on the street. This finding should be regarded through an intersectional lens, as trans women already face disproportionate levels of employment discrimination (Grant et al., 2011). The fact that they are forced into the sex work industry (Nadal et al., 2014) due to widespread transphobia from within all sectors of society (Blewett and Law, 2018; GNSWP, 2022; Logie et al., 2017; Zangger, 2015) makes their further marginalisation within the industry even more dangerous. A similar intersectional view is needed for the findings related to refugees being excluded from the industry’s managed sector, mostly due to not having identification papers (Jamil et al., 2012). This finding, compounded with limitations in accessing employment and, even more crucially, legal protection, lack of legal status and increased risk of deportation constructs unique experiences of marginalisation and disadvantage (Boonzaier, 2019; Rosenberg and Bakomeza, 2017).

Motherhood, on the other hand, was not related to a specific type of sex work (Minescu et al., 2022), possibly because the majority of our sample were people on the move, who often report leaving their children in their country of origin in order to be able to work long hours and provide for them (Karandikar et al., 2022). Unfortunately, we have no such measures and data collected. Nonetheless, it is shown that many female sex workers in Athens as well are indeed mothers, like in many other cities (Blanchard et al., 2018; Duff et al., 2015; Minescu et al., 2022; Renshaw et al., 2015), despite popular detachment myths (Azhar et al., 2020; Poulios, 2018). Stigma related to said myths, as well as criminalisation and other marginalising factors set obstacles to sex workers’ maternal capacity and challenge their and their children’s health, safety, well-being and human rights (Ma et al., 2018).

In line with Drydakis’ (2022) study, health issues were associated with street-based sex work in the present study. In general, the fact that street-based sex work is associated with perceived problematic substance use, homelessness, health issues, client violence and police issues paints a vivid picture of the current situation in street-based sex work in Athens, and the criminalisation of street-based sex work is highly problematic and impactful on their lives. Perceived illegal substance use associated with street sex work (Aidala and Sumartojo, 2007; Duff et al., 2015; Minescu et al., 2022), for instance, may be attributed to coping with stressors existing within the criminalised sector of the industry (Burnes et al., 2012; Minescu et al., 2022). Criminalisation also leads to health disparities, as street-based sex workers often limit their negotiation time and work in unsafe corners to avoid trouble with the police (Goldenberg et al., 2017). The more commonly reported client violence and troubles with the police, as well as the health disparities, were related to the partial criminalisation legal model, which criminalises street-based sex work in most of the countries that implement it, including Greece (Jahnsen and Wagenaar, 2019; Weitzer, 2017). Client violence and police issues being reported more frequently by street-based sex workers show that indeed even partial criminalisation leads to unsafety (Blanchard et al., 2018; GNSWP, 2022; Logie et al., 2017; Platt et al., 2018; Tomko et al., 2021; Weitzer, 2017; Wirtz et al., 2015; Zangger, 2015).

LIMITATIONS

The generalisability of the study’s results is limited as the sample was collected in one location, in a sex workers’ day centre in Athens, Greece. Therefore, sex workers from other urban or rural areas of Greece, or those that are unlikely to visit a sex workers’ community centre are not represented here. Additionally, although motherhood was measured, child caregiving was omitted, which is important information in children stay-behind migration contexts. Finally, we were unable to control for confounding variables that may have affected the relationship between street-based sex work and specific identities and precarity factors, such as socio-economic status. Therefore, we present this research as specific to these empirical factors, although inferences can be drawn in terms of relevance to other cities.

CONCLUSIONS

This piece of local community research has identified how intersectional and diverse factors influence the lives of sex workers in a major European city. Welfare and care interventions designed for street-based sex workers should incorporate harm reduction practices, by offering safer injection kits or referrals to supervised consumption sites (Lew et al., 2022) and gender-affirmative care (Aldridge et al., 2021), as well as multilingual and multicultural interpretation (Lifland et al., 2022), housing and legal support (Minescu et al., 2022).

Full decriminalisation of sex work is recommended in order to reduce exploitation, violence, and abuse in the current criminalised framework, and the harms and risks associated with street-based sex work in particular and all other forms in general (Benoit et al., 2021; Brooks-Gordon et al., 2021). Additionally, the need for service provision for sex-working mothers and their children is linked to the development of inclusive policies and legislative frameworks (Dodsworth, 2012). Especially considering that the current Greek law forces sex workers to be single (Jahnsen and Wagenaar, 2019; Law 2734/1999, 1999), which constitutes marital status discrimination and can be interpreted as a violation of human rights and labour laws.

Last but not least, it should also be stressed that all these precarity factors are interrelated. The lack of safe accommodation, for instance, is linked to more risky behaviours for street sex workers, intensifying violence and a sense of insecurity, substance use, trouble with the police and health problems (Aidala and Sumartojo, 2007; Armstrong, 2017; Duff et al., 2011; Goldenberg et al., 2020; Logie et al., 2017; Minescu et al., 2022; Shannon et al., 2009). Therefore, interventions designed for street-based sex workers should make plans that take account of the multiple, intersecting factors at play that form interactive elements of a distinct experience (Boonzaier, 2019). Furthermore, by fostering cooperation between civil society organisations, a comprehensive and holistic approach can be developed to address the unique marginalisation faced by trans and refugee sex workers (Ciccia and Roggeband, 2021).