Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
Decriminalization of sex work in the United States is limited to Nevada. In 1980 the Nevada Supreme Court legalized sex work in smaller counties with population under 400,0001. Removal of criminal penalties for sex work allows workers to receive protection and recognition like any other industry. Sex workers who are protected by decriminalization have increased ability to negotiate and are less likely to be sexually coerced and raped 2,3. While not intended as a health policy, decriminalization of sex work is known to decrease sexually transmitted infection (STI) rates and likely has other health implications.
Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
Determining the effects of this Supreme Court ruling would provide data on other outcomes including health outcomes outside of sexually transmitted infections. It would be potentially helpful in determining significant health benefits of decimalization and may incentivize other states to follow suit.
Specify the outcomes and populations you think most affected or least affected by the policy.
Populations: The most vulnerable sex workers are those who would be most affected by decriminalization. This includes those with lower SES, housing instability and substance use disorders. Those who may be least affected include white escorts who are less likely to be prosecuted for sex work without decriminalization.
Outcomes:
· sexual assault
· STI
· unintended pregnancy
· mental health
· economic status
· police record
· Public cost of incarceration/prosecution
Propose a study design to evaluate the policy.
Assuming a perfect world where data regarding sex workers pre 1980 and post 1980 existed, I would perform a retrospective cohort study looking at STI and unintended pregnancy rates, mental health outcomes and economic status both before and after the supreme court ruling.
If this data was not available, a qualitative study with in depth interviews with sex workers who worked before and after the supreme court ruling could be performed. This approach would be far more
Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
There are many limitations to drawing causal inferences from the impact of the Nevada supreme court policy. There are many confounders, many which we would not have data to measure and others that are unknown. These confounders could include other national, state or community policy changes, change in local resources or services, or a general shift in the economy. If a new policy were put in place now, we would have more control over measurements of confounders. In this case, collecting data from 40 years ago would prove difficult with undoubtedly many gaps.
References:
1. Snadowsky, D. (2005). The Best Little Whorehouse is Not in Texas: How Nevada's Prostitution Laws Serve Public Policy, and How Those Laws May be Improved. Nev. LJ, 6, 217.
2. World Health Organization. (2016). New WHO guidelines to better prevent HIV in sex workers. December 12, 2012.
3. World Health Organization. (2005). Violence against sex workers and HIV prevention. Geneva: WHO.